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Smith J, Cvejic E, Houssami N, Schonberg MA, Vincent W, Naganathan V, Jansen J, Dodd RH, Wallis K, McCaffery KJ. Randomized Trial of Information for Older Women About Cessation of Breast Cancer Screening Invitations. J Gen Intern Med 2024; 39:1332-1341. [PMID: 38409512 PMCID: PMC11169431 DOI: 10.1007/s11606-024-08656-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 01/24/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Older women receive no information about why Australia's breast screening program (BreastScreen) invitations cease after 74 years. We tested how providing older women with the rationale for breast screening cessation impacted informed choice (adequate knowledge; screening attitudes aligned with intention). METHODS In a three-arm online randomized trial, eligible participants were females aged 70-74 years who had recently participated in breast screening (within 5 years), without personal breast cancer history, recruited through Qualtrics. Participants read a hypothetical scenario in which they received a BreastScreen letter reporting no abnormalities on their mammogram. They were randomized to receive the letter: (1) without any rationale for screening cessation (control); (2) with screening cessation rationale in printed-text form (e.g., downsides of screening outweigh the benefits after age 74); or (3) with screening cessation rationale presented in an animation video form. The primary outcome was informed choice about continuing/stopping breast screening beyond 74 years. RESULTS A total of 376 participant responses were analyzed. Compared to controls (n = 122), intervention arm participants (text [n = 132] or animation [n = 122]) were more likely to make an informed choice (control 18.0%; text 32.6%, p = .010; animation 40.5%, p < .001). Intervention arm participants had more adequate knowledge (control 23.8%; text 59.8%, p < .001; animation 68.9%, p < .001), lower screening intentions (control 17.2%; text 36.4%, p < .001; animation 49.2%, p < .001), and fewer positive screening attitudes regarding screening for themselves in the animation arm, but not in the text arm (control 65.6%; text 51.5%, p = .023; animation 40.2%, p < .001). CONCLUSIONS Providing information to older women about the rationale for breast cancer screening cessation increased informed decision-making in a hypothetical scenario. This study is an important first step in improving messaging provided by national cancer screening providers direct to older adults. Further research is needed to assess the impact of different elements of the intervention and the impact of providing this information in clinical practice, with more diverse samples. TRIAL REGISTRATION ANZCTRN12623000033640.
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Affiliation(s)
- Jenna Smith
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Erin Cvejic
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Nehmat Houssami
- The Daffodil Centre, The University of Sydney, a joint venture with the Cancer Council NSW, Sydney, NSW, Australia
| | - Mara A Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Wendy Vincent
- BreastScreen NSW, Sydney Local Health District, Sydney, NSW, Australia
| | - Vasi Naganathan
- Faculty of Medicine and Health, Concord Clinical School, The University of Sydney, Sydney, Australia
- Department of Geriatric Medicine, Centre for Education and Research On Ageing, Concord Hospital, Concord, NSW, Australia
| | - Jesse Jansen
- Faculty of Health, Medicine and Life Sciences, School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands
| | - Rachael H Dodd
- The Daffodil Centre, The University of Sydney, a joint venture with the Cancer Council NSW, Sydney, NSW, Australia
| | - Katharine Wallis
- General Practice Clinical Unit, Medical School, The University of Queensland, Brisbane, QLD, Australia
| | - Kirsten J McCaffery
- Edward Ford Building (A27), The University of Sydney, Sydney, NSW, Australia.
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Saini SD, Lewis CL, Kerr EA, Zikmund-Fisher BJ, Hawley ST, Forman JH, Zauber AG, Lansdorp-Vogelaar I, van Hees F, Saffar D, Myers A, Gauntlett LE, Lipson R, Kim HM, Vijan S. Personalized Multilevel Intervention for Improving Appropriate Use of Colorectal Cancer Screening in Older Adults: A Cluster Randomized Clinical Trial. JAMA Intern Med 2023; 183:1334-1342. [PMID: 37902744 PMCID: PMC10616770 DOI: 10.1001/jamainternmed.2023.5656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 09/01/2023] [Indexed: 10/31/2023]
Abstract
Importance Despite guideline recommendations, clinicians do not systematically use prior screening or health history to guide colorectal cancer (CRC) screening decisions in older adults. Objective To evaluate the effect of a personalized multilevel intervention on screening orders in older adults due for average-risk CRC screening. Design, Setting, and Participants Interventional 2-group parallel unmasked cluster randomized clinical trial conducted from November 2015 to February 2019 at 2 US Department of Veterans Affairs (VA) facilities: 1 academic VA medical center and 1 of its connected outpatient clinics. Randomization at the primary care physician/clinician (PCP) level, stratified by study site and clinical full-time equivalency. Participants were 431 average-risk, screen-due US veterans aged 70 to 75 years attending a primary care visit. Data analysis was performed from August 2018 to August 2023. Intervention The intervention group received a multilevel intervention including a decision-aid booklet with detailed information on screening benefits and harms, personalized for each participant based on age, sex, prior screening, and comorbidity. The control group received a multilevel intervention including a screening informational booklet. All participants received PCP education and system-level modifications to support personalized screening. Main Outcomes and Measures The primary outcome was whether screening was ordered within 2 weeks of clinic visit. Secondary outcomes were concordance between screening orders and screening benefit and screening utilization within 6 months. Results A total of 436 patients were consented, and 431 were analyzed across 67 PCPs. Patients had a mean (SD) age of 71.5 (1.7) years; 424 were male (98.4%); 374 were White (86.8%); 89 were college graduates (21.5%); and 351 (81.4%) had undergone prior screening. A total of 258 (59.9%) were randomized to intervention, and 173 (40.1%) to control. Screening orders were placed for 162 of 258 intervention patients (62.8%) vs 114 of 173 control patients (65.9%) (adjusted difference, -4.0 percentage points [pp]; 95% CI, -15.4 to 7.4 pp). In a prespecified interaction analysis, the proportion receiving orders was lower in the intervention group than in the control group for those in the lowest benefit quartile (59.4% vs 71.1%). In contrast, the proportion receiving orders was higher in the intervention group than in the control group for those in the highest benefit quartile (67.6% vs 52.2%) (interaction P = .049). Fewer intervention patients (106 of 256 [41.4%]) utilized screening overall at 6 months than controls (96 of 173 [55.9%]) (adjusted difference, -13.4 pp; 95% CI, -25.3 to -1.6 pp). Conclusions and Relevance In this cluster randomized clinical trial, patients who were presented with personalized information about screening benefits and harms in the context of a multilevel intervention were more likely to receive screening orders concordant with benefit and were less likely to utilize screening. Trial Registration ClinicalTrials.gov Identifier: NCT02027545.
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Affiliation(s)
- Sameer D. Saini
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | | | - Eve A. Kerr
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Brian J. Zikmund-Fisher
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor
| | - Sarah T. Hawley
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Jane H. Forman
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Darcy Saffar
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
| | - Aimee Myers
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
| | - Lauren E. Gauntlett
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
| | - Rachel Lipson
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
| | - H. Myra Kim
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
- Consulting for Statistics, Computing and Analytics Research (CSCAR), University of Michigan, Ann Arbor
| | - Sandeep Vijan
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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Issaka RB, Chan AT, Gupta S. AGA Clinical Practice Update on Risk Stratification for Colorectal Cancer Screening and Post-Polypectomy Surveillance: Expert Review. Gastroenterology 2023; 165:1280-1291. [PMID: 37737817 PMCID: PMC10591903 DOI: 10.1053/j.gastro.2023.06.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/20/2023] [Accepted: 06/30/2023] [Indexed: 09/23/2023]
Abstract
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.
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Affiliation(s)
- Rachel B Issaka
- Public Health Sciences and Clinical Research Divisions, Fred Hutchinson Cancer Center, Seattle, Washington; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington.
| | - Andrew T Chan
- Clinical and Translational Epidemiology Unit, Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Samir Gupta
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California; Section of Gastroenterology, Jennifer Moreno Department of Medical Affairs Medical Center, San Diego, California
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Chiu LS, Calderwood AH. Noninvasive Colorectal Cancer Prevention Options in Older Adults. J Clin Gastroenterol 2023; 57:855-862. [PMID: 37436836 DOI: 10.1097/mcg.0000000000001893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
Colorectal cancer (CRC) is a leading cause of morbidity and mortality worldwide and its incidence increases with age. The proportion of older adults in the United States continues to rise, making CRC prevention a key health priority for our aging population. CRC is a largely preventable disease through screening and polyp surveillance, and noninvasive modalities represent an important option for older adults in whom the burdens and risks of invasive testing are higher compared with younger adults. This review highlights the evidence, risks, and benefits of noninvasive CRC screening and surveillance options in older adults and discusses the challenges of CRC prevention in this cohort.
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Affiliation(s)
- Laura S Chiu
- Department of Medicine, Section of Gastroenterology, Boston University School of Medicine, Boston, MA
| | - Audrey H Calderwood
- Department of Medicine, Section of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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5
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Wang T, Dossett LA. Incorporating Value-Based Decisions in Breast Cancer Treatment Algorithms. Surg Oncol Clin N Am 2023; 32:777-797. [PMID: 37714643 DOI: 10.1016/j.soc.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
Given the excellent prognosis and availability of evidence-based treatment, patients with early-stage breast cancer are at risk of overtreatment. In this review, we summarize key opportunities to incorporate value-based decisions to optimize the delivery of high-value treatment across the breast cancer care continuum.
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Affiliation(s)
- Ton Wang
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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Brotzman LE, Zikmund-Fisher BJ. Perceived Barriers Among Clinicians and Older Adults Aged 65 and Older Regarding Use of Life Expectancy to Inform Cancer Screening: A Narrative Review and Comparison. Med Care Res Rev 2023; 80:372-385. [PMID: 36800914 DOI: 10.1177/10775587231153269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
While cancer screening guidelines increasingly recommend incorporating life expectancy estimates to inform screening decisions for older adults, little is known about how this happens in practice. This review summarizes current knowledge about primary care clinician and older adult (65+) perspectives about use of life expectancy to guide cancer screening decisions. Clinicians report operational barriers, uncertainty, and hesitation around use of life expectancy in screening decisions. They recognize it may help them more accurately weigh benefits and harms but are unsure how to estimate life expectancy for individual patients. Older adults face conceptual barriers and are generally unconvinced of the benefits of considering their life expectancy when making screening decisions. Life expectancy will always be a difficult topic for clinicians and patients, but there are advantages to incorporating it in cancer screening decisions. We highlight key takeaways from both clinician and older adult perspectives to guide future research.
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Galang K, Polychronopoulou E, Sharma G, Nishi SP. A Closer Look-Who Are We Screening for Lung Cancer? Mayo Clin Proc Innov Qual Outcomes 2023; 7:171-177. [PMID: 37293510 PMCID: PMC10244365 DOI: 10.1016/j.mayocpiqo.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/31/2023] [Accepted: 04/05/2023] [Indexed: 06/10/2023] Open
Abstract
Objective To evaluate the characteristics of individuals receiving lung cancer screening (LCS) and identify those with potentially limited benefit owing to coexisting chronic illnesses and/or comorbidities. Patients and Methods In this retrospective study in the United States, patients were selected from a large clinical database who received LCS from January 1, 2019, through December 31, 2019, with at least 1 year of continuous enrollment. We assessed for potentially limited benefit in LCS defined strictly as not meeting the traditional risk factor inclusion criteria (age <55 years or >80 years, previous computed tomography scan within 11 months before an LCS examination, or a history of nonskin cancer) or liberally as having the potential exclusion criteria related to comorbid life-limiting conditions, such as cardiac and/or respiratory disease. Results A total of 51,551 patients were analyzed. Overall, 8391 (16.3%) individuals experienced a potentially limited benefit from LCS. Among those who did not meet the strict traditional inclusion criteria, 317 (3.8%) were because of age, 2350 (28%) reported a history of nonskin malignancy, and 2211 (26.3%) underwent a previous computed tomography thorax within 11 months before an LCS examination. Of those with potentially limited benefit owing to comorbidity, 3680 (43.9%) were because of severe respiratory comorbidity (937 [25.5%] with any hospitalization for coronary obstructive pulmonary disease, interstitial lung disease, or respiratory failure; 131 [3.6%] with hospitalization for respiratory failure requiring mechanical ventilation; or 3197 [86.9%] with chronic obstructive disease/interstitial lung disease requiring outpatient oxygen) and 721 (8.59%) with cardiac comorbidity. Conclusion Up to 1 of 6 low-dose computed tomography examinations may have limited benefit from LCS.
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Affiliation(s)
- Kristine Galang
- Department of Internal Medicine, University of Texas Medical Branch–Galveston, Galveston, TX
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Texas Medical Branch–Galveston, Galveston, TX
| | | | - Gulshan Sharma
- Department of Internal Medicine, University of Texas Medical Branch–Galveston, Galveston, TX
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Texas Medical Branch–Galveston, Galveston, TX
- Sealy Center on Aging, University of Texas Medical Branch–Galveston, Galveston, TX
| | - Shawn P.E. Nishi
- Department of Internal Medicine, University of Texas Medical Branch–Galveston, Galveston, TX
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Texas Medical Branch–Galveston, Galveston, TX
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Calderwood AH, Tosteson TD, Wang Q, Onega T, Walter LC. Association of Life Expectancy With Surveillance Colonoscopy Findings and Follow-up Recommendations in Older Adults. JAMA Intern Med 2023; 183:426-434. [PMID: 36912828 PMCID: PMC10012041 DOI: 10.1001/jamainternmed.2023.0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 01/11/2023] [Indexed: 03/14/2023]
Abstract
Importance Surveillance after prior colon polyps is the most frequent indication for colonoscopy in older adults. However, to our knowledge, the current use of surveillance colonoscopy, clinical outcomes, and follow-up recommendations in association with life expectancy, factoring in both age and comorbidities, have not been studied. Objective To evaluate the association of estimated life expectancy with surveillance colonoscopy findings and follow-up recommendations among older adults. Design, Setting, and Participants This registry-based cohort study used data from the New Hampshire Colonoscopy Registry (NHCR) linked with Medicare claims data and included adults in the NHCR who were older than 65 years, underwent colonoscopy for surveillance after prior polyps between April 1, 2009, and December 31, 2018, and had full Medicare Parts A and B coverage and no Medicare managed care plan enrollment in the year prior to colonoscopy. Data were analyzed from December 2019 to March 2021. Exposures Life expectancy (<5 years, 5 to <10 years, or ≥10 years), estimated using a validated prediction model. Main Outcomes and Measures The main outcomes were clinical findings of colon polyps or colorectal cancer (CRC) and recommendations for future colonoscopy. Results Among 9831 adults included in the study, the mean (SD) age was 73.2 (5.0) years and 5285 (53.8%) were male. A total of 5649 patients (57.5%) had an estimated life expectancy of 10 or more years, 3443 (35.0%) of 5 to less than 10 years, and 739 (7.5%) of less than 5 years. Overall, 791 patients (8.0%) had advanced polyps (768 [7.8%]) or CRC (23 [0.2%]). Among the 5281 patients with available recommendations (53.7%), 4588 (86.9%) were recommended to return for future colonoscopy. Those with longer life expectancy or more advanced clinical findings were more likely to be told to return. For example, among patients with no polyps or only small hyperplastic polyps, 132 of 227 (58.1%) with life expectancy of less than 5 years were told to return for future surveillance colonoscopy vs 940 of 1257 (74.8%) with life expectancy of 5 to less than 10 years and 2163 of 2272 (95.2%) with life expectancy of 10 years or more (P < .001). Conclusions and Relevance In this cohort study, the likelihood of finding advanced polyps and CRC on surveillance colonoscopy was low regardless of life expectancy. Despite this observation, 58.1% of older adults with less than 5 years' life expectancy were recommended to return for future surveillance colonoscopy. These data may help refine decision-making about pursuing or stopping surveillance colonoscopy in older adults with a history of polyps.
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Affiliation(s)
- Audrey H. Calderwood
- Department of Medicine, Dartmouth-Hitchcock Medical Cancer, Lebanon, New Hampshire
- The Dartmouth Institute at Geisel School of Medicine, Lebanon, New Hampshire
| | - Tor D. Tosteson
- The Dartmouth Institute at Geisel School of Medicine, Lebanon, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
- Department of Community and Family Medicine, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Qianfei Wang
- The Dartmouth Institute at Geisel School of Medicine, Lebanon, New Hampshire
| | - Tracy Onega
- Huntsman Cancer Institute, Department of Population Health Sciences, University of Utah, Salt Lake City
| | - Louise C. Walter
- Division of Geriatrics, University of California, San Francisco
- VA Health Care System, San Francisco, California
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Gram EG, Knudsen SW, Brodersen JB, Jønsson ABR. Women's experiences of age-related discontinuation from mammography screening: A qualitative interview study. Health Expect 2023; 26:1096-1106. [PMID: 36807965 PMCID: PMC10154894 DOI: 10.1111/hex.13723] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 01/27/2023] [Accepted: 01/27/2023] [Indexed: 02/20/2023] Open
Abstract
INTRODUCTION In Denmark, women are discontinued from mammography screening at age 69 due to decreased likelihood of benefits and increased likelihood of harm. The risk of harm increases with age and includes false positives, overdiagnosis and overtreatment. In a questionnaire survey, 24 women expressed unsolicited concerns about being discontinued from mammography screening due to age. This calls for further investigation of experiences related to discontinuation from screening. METHODS We invited the women, who had left comments on the questionnaire, to participate in in-depth interviews with the purpose to explore their reactions, preferences, and conceptions about mammography screening and discontinuation. The interviews lasted 1-4 h and were followed up with a telephone interview 2 weeks after the initial interview. RESULTS The women had high expectations of the benefits of mammography screening and felt that participation was a moral obligation. Following that, they perceived the screening discontinuation as a result of societal age discrimination and consequently felt devalued. Further, the women perceived the discontinuation as a health threat, felt more susceptible to late diagnosis and death, and therefore sought out new ways to control their risk of breast cancer. CONCLUSION Our findings indicate that the age-related discontinuation from mammography screening might be of more importance than previously assumed. This study raises important questions about screening ethics, and we encourage research to explore this in other settings. PATIENT AND PUBLIC CONTRIBUTION This study was conducted as a result of the women's unsolicited concerns about being discontinued from screening. This particular group contributed to the study with their own statements, interpretations and perspectives on the discontinuation of screening, and the initial analysis of data was discussed with the women during follow-up interviews.
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Affiliation(s)
- Emma G Gram
- Center for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Primary Health Care Research Unit, Region Zealand, Denmark
| | - Sigrid W Knudsen
- Center for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - John Brandt Brodersen
- Center for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Primary Health Care Research Unit, Region Zealand, Denmark.,The Research Unit for General Practice, Department of Social Medicine, University of Tromsø, Tromsø, Norway
| | - Alexandra Brandt R Jønsson
- Center for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of People and Technology, Roskilde University, Roskilde, Denmark.,The Research Unit for General Practice, Department of Social Medicine, University of Tromsø, Tromsø, Norway
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Guittet L, Quipourt V, Aparicio T, Carola E, Seitz JF, Paillaud E, Lievre A, Boulahssass R, Vitellius C, Bengrine L, Canoui-Poitrine F, Manfredi S. Should we screen for colorectal cancer in people aged 75 and over? A systematic review - collaborative work of the French geriatric oncology society (SOFOG) and the French federation of digestive oncology (FFCD). BMC Cancer 2023; 23:17. [PMID: 36604640 PMCID: PMC9817257 DOI: 10.1186/s12885-022-10418-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/06/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND We have done a systematic literature review about CRC Screening over 75 years old in order to update knowledge and make recommendations. METHODS PUBMED database was searched in October 2021 for articles published on CRC screening in the elderly, and generated 249 articles. Further searches were made to find articles on the acceptability, efficacy, and harms of screening in this population, together with the state of international guidelines. RESULTS Most benefit-risk data on CRC screening in the over 75 s derived from simulation studies. Most guidelines recommend stopping cancer screening at the age of 75. In private health systems, extension of screening up to 80-85 years is, based on the life expectancy and the history of screening. Screening remains effective in populations without comorbidity given their better life-expectancy. Serious adverse events of colonoscopy increase with age and can outweigh the benefit of screening. The great majority of reviews concluded that screening between 75 and 85 years must be decided case by case. CONCLUSION The current literature does not allow Evidence-Based Medicine propositions for mass screening above 75 years old. As some subjects over 75 years may benefit from CRC screening, we discussed ways to introduce CRC screening in France in the 75-80 age group. IRB: An institutional review board composed of members of the 2 learned societies (SOFOG and FFCD) defined the issues of interest, followed the evolution of the work and reviewed and validated the report.
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Affiliation(s)
- Lydia Guittet
- grid.412043.00000 0001 2186 4076Public Health Unit, CHU Caen NormandieNormandie University, UNICAEN, INSERM U1086 ANTICIPE, Caen, France
| | - Valérie Quipourt
- grid.31151.37Geriatrics Department and Coordination Unit in Oncogeriatry in Burgundy, University Hospital of Dijon, Dijon, France
| | - Thomas Aparicio
- Department of Gastroenterology and Digestive Oncology, Saint Louis Hospital, APHP, Université de Paris, Paris, France
| | - Elisabeth Carola
- grid.418090.40000 0004 1772 4275Geriatric Oncology Unit, Groupe Hospitalier Public du Sud de L’Oise, Bd Laennec, 60100 Creil, France
| | - Jean-François Seitz
- grid.411266.60000 0001 0404 1115Department of Digestive Oncology & Gastroenterology, CHU Timone, Assistance Publique-Hôpitaux de Marseille (APHM) & Aix-Marseille-Univ, Marseille, France
| | - Elena Paillaud
- grid.414093.b0000 0001 2183 5849Geriatric Oncology Unit, Georges Pompidou European Hospital, Paris Cancer Institute CARPEM, inAP-HP, Paris, France
| | - Astrid Lievre
- grid.414271.5Department of Gastroenterology, INSERM U1242 “Chemistry Oncogenesis Stress Signaling”, University Hospital Pontchaillou, Rennes 1 University, Rennes, FFCD France
| | - Rabia Boulahssass
- grid.410528.a0000 0001 2322 4179Geriatric Coordination Unit for Geriatric Oncology (UCOG), PACA Est CHU de NICE, France; FHU ONCOAGE, Nice, France
| | - Carole Vitellius
- grid.411147.60000 0004 0472 0283Hepato-Gastroenterology Department, Angers University Hospital, Angers, France ,grid.7252.20000 0001 2248 3363HIFIH Laboratory UPRES EA3859, Angers University, SFR 4208, Angers, France
| | - Leila Bengrine
- Department of Medical Oncology, Georges-Francois Leclerc Centre, Dijon, France
| | - Florence Canoui-Poitrine
- grid.412116.10000 0004 1799 3934Public Health Unit, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, 94000 Créteil, France
| | - Sylvain Manfredi
- grid.31151.37Gastroenterology and Digestive Oncology Unit, University Hospital Dijon, INSERM U123-1 University of Bourgogne-Franche-Comté, FFCD (French Federation of Digestive Cancer), Dijon, France
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11
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Smith J, Dodd RH, Wallis KA, Naganathan V, Cvejic E, Jansen J, McCaffery KJ. General practitioners' views and experiences of communicating with older people about cancer screening: a qualitative study. Fam Pract 2022:cmac126. [PMID: 36334011 DOI: 10.1093/fampra/cmac126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Jenna Smith
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Rachael H Dodd
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Katharine A Wallis
- General Practice Clinical Unit, The University of Queensland, Brisbane, QLD, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing, Department of Geriatric Medicine, Concord Repatriation Hospital, Concord, NSW, Australia
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Erin Cvejic
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jesse Jansen
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Kirsten J McCaffery
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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12
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Lee AK, Diaz-Ramirez LG, John Boscardin W, Smith AK, Lee SJ. A comprehensive prognostic tool for older adults: Predicting death, ADL disability, and walking disability simultaneously. J Am Geriatr Soc 2022; 70:2884-2894. [PMID: 35792836 PMCID: PMC9588505 DOI: 10.1111/jgs.17932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/03/2022] [Accepted: 05/23/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Alexandra K. Lee
- Division of Geriatrics, Department of Medicine, UCSF, San Francisco, CA
- San Francisco Veterans Affairs Healthcare System, San Francisco, CA
| | | | - W. John Boscardin
- Division of Geriatrics, Department of Medicine, UCSF, San Francisco, CA
- San Francisco Veterans Affairs Healthcare System, San Francisco, CA
- Division of Biostatistics, Department of Epidemiology and Biostatistics, UCSF, San Francisco, CA
| | - Alexander K. Smith
- Division of Geriatrics, Department of Medicine, UCSF, San Francisco, CA
- San Francisco Veterans Affairs Healthcare System, San Francisco, CA
| | - Sei J. Lee
- Division of Geriatrics, Department of Medicine, UCSF, San Francisco, CA
- San Francisco Veterans Affairs Healthcare System, San Francisco, CA
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13
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Characteristics Associated with Low-Value Cancer Screening Among Office-Based Physician Visits by Older Adults in the USA. J Gen Intern Med 2022; 37:2475-2481. [PMID: 34379279 PMCID: PMC9360208 DOI: 10.1007/s11606-021-07072-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND After a certain age, cancer screening may expose older adults to unnecessary harms with limited benefits and represent inefficient use of health care resources. OBJECTIVE To estimate the frequency of cervical, breast, and colorectal cancer screening among adults older than US Preventive Services Task Force (USPSTF) age thresholds at which screening is no longer considered routine and to identify physician and patient factors associated with low-value cancer screening. DESIGN Observational study using pooled cross-sectional data (2011-2016) from the National Ambulatory Medical Care Survey, a nationally representative probability sample of US office-based physician visits. PARTICIPANTS Analyses for cervical and breast cancer screening were limited to visits by women over age 65 (N=37,818) and ages 75 and over (N=19,451), respectively. Analyses for colorectal cancer screening were limited to visits by patients over age 75 (N=31,543). MAIN MEASURES Cancer screening procedures were coded as low value using USPSTF age thresholds. KEY RESULTS Between 2011 and 2016, an estimated 509, 507, and 273 thousand potentially low-value Pap smears, mammograms, and colonoscopies/sigmoidoscopies, respectively, were ordered annually. Low-valuecervical cancer screening was less likely to occur for visits with older (vs. younger) patients. Compared to visits by non-HispanicWhite women, low-valuecervical and breast cancer screening was less likely to occur for visits by women whose race/ethnicitywas something other than non-HispanicWhite, non-HispanicBlack, or Hispanic. Obstetrician/gynecologistswere more likely to order low-valuePap smears and mammograms compared to family/generalpractice physicians. CONCLUSIONS Thousands of cervical, breast, and colorectal cancer screenings at ages beyond routine guideline thresholds occur each year in the USA. Further research is needed to understand whether this pattern represents clinical inertia and resistance to de-adoption of previous screening practices, or whether physicians and/or patients perceive a higher value in these tests than that endorsed by experts writing evidence-based guidelines.
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14
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Brotzman LE, Shelton RC, Austin JD, Rodriguez CB, Agovino M, Moise N, Tehranifar P. "It's something I'll do until I die": A qualitative examination into why older women in the U.S. continue screening mammography. Cancer Med 2022; 11:3854-3862. [PMID: 35616300 PMCID: PMC9582674 DOI: 10.1002/cam4.4758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Professional guidelines in the U.S. do not recommend routine screening mammography for women ≥75 years with limited life expectancy and/or poor health. Yet, routine mammography remains widely used in older women. We examined older women's experiences, beliefs, and opinions about screening mammography in relation to aging and health. METHODS We performed thematic analysis of transcribed semi-structured interviews with 19 women who had a recent screening visit at a mammography clinic in New York City (average age: 75 years, 63% Hispanic, 53% ≤high school education). RESULTS Three main themes emerged: (1) older women typically perceive mammograms as a positive, beneficial, and routine component of care; (2) participation in routine mammography is reinforced by factors at interpersonal, provider, and healthcare system levels; and (3) older women do not endorse discontinuation of screening mammography due to advancing age or poor health, but some may be receptive to reducing screening frequency. Only a few older women reported having discussed mammography cessation or the potential harms of screening with their providers. A few women reported they would insist on receiving mammography even without a provider recommendation. CONCLUSIONS Older women's positive experiences and views, as well as multilevel and frequently automated cues toward mammography are important drivers of routine screening in older women. These findings suggest a need for synergistic patient, provider, and system level strategies to reduce mammography overuse in older women.
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Affiliation(s)
- Laura E. Brotzman
- Department of Sociomedical SciencesColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | - Rachel C. Shelton
- Department of Sociomedical SciencesColumbia University Mailman School of Public HealthNew YorkNew YorkUSA,Herbert Irving Comprehensive Cancer CenterColumbia University Medical CenterNew YorkNew YorkUSA
| | - Jessica D. Austin
- Department of Sociomedical SciencesColumbia University Mailman School of Public HealthNew YorkNew YorkUSA,Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | - Carmen B. Rodriguez
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | - Mariangela Agovino
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | - Nathalie Moise
- Department of MedicineColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Parisa Tehranifar
- Herbert Irving Comprehensive Cancer CenterColumbia University Medical CenterNew YorkNew YorkUSA,Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
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15
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Zhu X, Weiser E, Jacobson DJ, Griffin JM, Limburg PJ, Finney Rutten LJ. Factors Associated With Clinician Recommendations for Colorectal Cancer Screening Among Average-Risk Patients: Data From a National Survey. Prev Chronic Dis 2022; 19:E19. [PMID: 35420980 PMCID: PMC9044901 DOI: 10.5888/pcd19.210315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction Colorectal cancer (CRC) screening among average-risk patients is underused in the US. Clinician recommendation is strongly associated with CRC screening completion. To inform interventions that improve CRC screening uptake among average-risk patients, we examined clinicians’ routine recommendations of 7 guideline-recommended screening methods and factors associated with these recommendations. Methods We conducted an online survey in November and December 2019 among a sample of primary care clinicians (PCCs) and gastroenterologists (GIs) from a panel of US clinicians. Clinicians reported whether they routinely recommend each screening method, screening method intervals, and patient age at which they stop recommending screening. We also measured the influence of various factors on screening recommendations. Results Nearly all 814 PCCs (99%) and all 159 GIs (100%) reported that they routinely recommend colonoscopy for average-risk patients, followed by stool-based tests (more than two-thirds of PCCs and GIs). Recommendation of other visualization-based methods was less frequent (PCCs, 26%–35%; GIs, 30%–41%). A sizable proportion of clinicians reported guideline-discordant screening intervals and age to stop screening. Guidelines and clinical evidence were most frequently reported as very influential to clinician recommendations. Factors associated with routine recommendation of each screening method included clinician-perceived effectiveness of the method, clinician familiarity with the method, Medicare coverage, clinical capacity, and patient adherence. Conclusion Clinician education is needed to improve knowledge, familiarity, and experience with guideline-recommended screening methods with the goal of effectively engaging patients in informed decision making for CRC screening.
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Affiliation(s)
- Xuan Zhu
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | | | - Debra J. Jacobson
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Joan M. Griffin
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota
| | - Paul J. Limburg
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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16
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Enns JP, Pollack CE, Boyd CM, Massare J, Schoenborn NL. Discontinuing Cancer Screening for Older Adults: a Comparison of Clinician Decision-Making for Breast, Colorectal, and Prostate Cancer Screenings. J Gen Intern Med 2022; 37:1122-1128. [PMID: 34545468 PMCID: PMC8971256 DOI: 10.1007/s11606-021-07121-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/25/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND While guidelines recommend against routine screening for breast, prostate, and colorectal cancers in older adults (65+ years) with <10-year life expectancy, many of these patients continue to be screened. How clinicians consider screening cessation across multiple cancer screening types is unknown. OBJECTIVE To compare and contrast clinicians' perspectives on discontinuing breast, prostate, and colorectal cancer screenings in older adults. DESIGN Qualitative, semi-structured interviews. PARTICIPANTS Primary care clinicians in Maryland (N=30) APPROACH: We conducted semi-structured interviews with individual clinicians. Interviews were recorded, transcribed, and analyzed using standard techniques of qualitative content analysis to identify major themes. KEY RESULTS Participants were mostly physicians (24/30) and women (16/30). Four major themes highlighted differences in decision-making across cancer screenings: (1) Clinicians reported more often screening beyond guideline-recommended ages for breast and prostate cancers than colorectal cancer; (2) clinicians had different priorities when considering the benefits/harms of each screening; for example, some prioritized continuing colorectal cancer screening due to the test's high efficacy while others prioritized stopping colorectal cancer screening due to high procedural risk; some prioritized continuing prostate cancer screening due to poor outcomes from advanced prostate cancer while others prioritized stopping prostate cancer screening due to high false positive test rates and harms from downstream tests; (3) clinicians discussed harms of prostate and colorectal cancer screening more readily than for breast cancer screening; (4) clinicians perceived more involvement with gastroenterologists in colonoscopy decisions and less involvement from specialists for prostate and breast cancer screening. CONCLUSIONS Our results highlight the need for more explicit guidance on how to weigh competing considerations in cancer screening (such as test accuracy versus ease of cancer treatment after detection). Recognizing the complexity of the benefit/harms analysis as clinicians consider multiple cancer screenings, future decision support tools, and clinician education materials can specifically address the competing considerations.
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Affiliation(s)
- Justine P Enns
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Craig E Pollack
- The Johns Hopkins University School of Public Health, Baltimore, MD, USA
| | - Cynthia M Boyd
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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17
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Jindal SK, Karamourtopoulos M, Jacobson AR, Pinheiro A, Smith AK, Hamel MB, Schonberg MA. Strategies for discussing long‐term prognosis when deciding on cancer screening for adults over age 75. J Am Geriatr Soc 2022; 70:1734-1744. [DOI: 10.1111/jgs.17723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/12/2022] [Accepted: 02/06/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Shivani K. Jindal
- New England Geriatrics Research Education, and Clinical Center, VA Boston Health Care System Boston Massachusetts USA
- Section of Geriatrics, Department of Medicine Boston University School of Medicine Boston Massachusetts USA
| | - Maria Karamourtopoulos
- Division of General Medicine and Primary Care, Department of Medicine Harvard Medical School, Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | | | - Adlin Pinheiro
- Division of General Medicine and Primary Care, Department of Medicine Harvard Medical School, Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | - Alexander K. Smith
- Division of Geriatrics, Department of Medicine University of California San Francisco California USA
| | - Mary Beth Hamel
- Division of General Medicine and Primary Care, Department of Medicine Harvard Medical School, Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | - Mara A. Schonberg
- Division of General Medicine and Primary Care, Department of Medicine Harvard Medical School, Beth Israel Deaconess Medical Center Boston Massachusetts USA
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18
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Cadet T, Aliberti G, Karamourtopoulos M, Jacobson A, Gilliam EA, Primeau S, Davis R, Schonberg MA. Evaluation of a mammography decision aid for women 75 and older at risk for lower health literacy in a pretest-posttest trial. PATIENT EDUCATION AND COUNSELING 2021; 104:2344-2350. [PMID: 33637391 PMCID: PMC8364563 DOI: 10.1016/j.pec.2021.02.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 01/16/2021] [Accepted: 02/09/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The evaluation of the effect of a mammography decision aid (DA) designed for older women at risk for lower health literacy (LHL) on their knowledge of mammography's benefits and harms and decisional conflict. METHODS Using a pretest-posttest design, women > 75 years at risk for LHL reviewing a mammography DA before and after their [B] primary care provider visit. Women were recruited from an academic medical center and community health centers and clinics. RESULTS Of 147 eligible women approached, 43 participated. Receipt of the DA significantly affected knowledge of mammography's benefits and harms [B] (pre-test (M = 3.75, SD = 1.05) to post-test (M = 4.42, SD = 1.19), p = .03). Receipt of the DA did not significantly affect decisional conflict (pre-test (M = 3.10, SD = .97) to post-test (M = 3.23, SD = 1.02), p = .71, higher scores = lower decisional conflict). The majority of the women (97%) indicated that the DA was helpful. CONCLUSIONS Women found a mammography screening DA helpful and its use was associated with these women having increased knowledge of mammography's benefits and harms. PRACTICE IMPLICATIONS With the shift toward shared decision-making for women > 75 years, there is a need to engage women of all literacy levels to participate in these decisions and have tools such as the one tested in this study.
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Affiliation(s)
- Tamara Cadet
- Simmons University College of Social Sciences and Policy Practice, School of Social Work, 300 The Fenway, Boston, MA, USA.
| | - Gianna Aliberti
- Beth Israel Deaconess Medical Center, 1309 Beacon St, Ste 202, Brookline, MA, USA
| | | | - Alicia Jacobson
- Beth Israel Deaconess Medical Center, 1309 Beacon St, Ste 202, Brookline, MA, USA
| | - Elizabeth A Gilliam
- Beth Israel Deaconess Medical Center, 1309 Beacon St, Ste 202, Brookline, MA, USA
| | - Sara Primeau
- Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA, USA
| | - Roger Davis
- Beth Israel Deaconess Medical Center, 1309 Beacon St, Ste 202, Brookline, MA, USA
| | - Mara A Schonberg
- Beth Israel Deaconess Medical Center, 1309 Beacon St, Ste 202, Brookline, MA, USA
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19
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What Should We Recommend for Colorectal Cancer Screening in Adults Aged 75 and Older? ACTA ACUST UNITED AC 2021; 28:2540-2547. [PMID: 34287279 PMCID: PMC8293045 DOI: 10.3390/curroncol28040231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/30/2021] [Accepted: 07/06/2021] [Indexed: 12/14/2022]
Abstract
The current recommendation to stop colorectal cancer screening for older adults is based on a lack of evidence due to systematic exclusion of this population from trials. Older adults are a heterogenous population with many available strategies for patient-centered assessment and decision-making. Evolutions in management strategies for colorectal cancer have made safe and effective options available to older adults, and the rationale to screen for treatable disease more reasonably, especially given the aging Canadian population. In this commentary, we review the current screening guidelines and the evidence upon which they were built, the unique considerations for screening older adults, new treatment options, the risks and benefits of increased screening and potential considerations for the new guidelines.
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20
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Calderwood AH, Carter C, Durand MA, O’Connor S, Boardman M. Impact of Knowledge and Risk Perceptions on Older Adults' Intention for Surveillance Colonoscopy. J Clin Gastroenterol 2021; 55:528-533. [PMID: 32740100 PMCID: PMC10851922 DOI: 10.1097/mcg.0000000000001401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/27/2020] [Indexed: 12/10/2022]
Abstract
GOALS The authors aimed to characterize older adults' intentions for future surveillance colonoscopy, knowledge of polyps, and predictors of colonoscopy plans. BACKGROUND Guidelines recommend that the decision to continue or stop surveillance colonoscopy in older adults with colon polyps be "individualized." Although older adults want to be included in decision making, how knowledge regarding polyps influences decisions is unknown. STUDY In collaboration with a rural family medicine practice, the authors invited adults aged 65 years and older with a history of colon adenomas to complete a 14-item survey regarding intention for colonoscopy and knowledge of colon polyps. RESULTS Sixty-seven of 105 (63%) patients completed the survey. The mean age was 72 years. Regarding future surveillance, 53% planned to return, 25% were unsure, and 22% did not plan to return. There were no significant differences in baseline characteristics on the basis of the intention for future colonoscopy. Regarding polyp knowledge, 73% had correct knowledge around how common polyps are; 50% thought that more than half of untreated polyps would become cancerous-an inaccurately elevated perception by 10 folds. Respondents who perceived polyps to have a high malignant potential were more likely to report plans for surveillance colonoscopy (68% vs. 39%; P=0.03). CONCLUSIONS In this survey of older adults with a history of polyps, many had a falsely elevated perception of polyps' potential for cancer that was associated with a higher intention for future colonoscopy. Ensuring older adults have an understanding of the risks of polyps is an essential step toward improving decision making around surveillance colonoscopy.
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Affiliation(s)
- Audrey H. Calderwood
- Dartmouth-Hitchcock Medical Center, Lebanon
- The Dartmouth Institute of Health Policy and Clinical Practice, Lebanon
- Dartmouth’s Geisel School of Medicine, Hanover, NH
| | | | - Marie-Anne Durand
- The Dartmouth Institute of Health Policy and Clinical Practice, Lebanon
- Université Toulouse III Paul Sabatier, Toulouse, France
| | - Sharon O’Connor
- Center for Program Design and Evaluation, Dartmouth College, Hanover, NH
| | - Maureen Boardman
- Dartmouth’s Geisel School of Medicine, Hanover, NH
- Dartmouth Primary Care Cooperative Research Network, Dartmouth’s Geisel School of Medicine, Hanover, NH
- Little Rivers Health Care, Bradford, VT
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21
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Abstract
PURPOSE OF REVIEW The risks of developing cancer and dementia both increase with age, giving rise to the complex question of whether continued cancer screening for older dementia patients is appropriate. This paper offers a practice-based clinical approach to determine an answer to this challenging question. RECENT FINDINGS There is no consensus on the prevalence of cancer and dementia as co-diagnoses. Persons with dementia are screened less often compared to those without dementia. There is significant literature focusing on screening in the geriatric population, but there is little evidence to support decision-making for screening for older patients with dementia. Given this lack of evidence, individualized decisions should be made in collaboration with patients and family caregivers. Four considerations to help guide this process include prognosis, behavioral constraints, cognitive capacity, and goals for care. Future research will be challenging due to variability of factors that inform screening decisions and the vulnerable nature of this patient population.
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Cadet T, Aliberti G, Karamourtopoulos M, Jacobson A, Siska M, Schonberg MA. Modifying a Mammography Decision Aid for Older Adult Women with Risk Factors for Low Health Literacy. Health Lit Res Pract 2021; 5:e78-e90. [PMID: 34213995 PMCID: PMC8082954 DOI: 10.3928/24748307-20210308-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Guidelines recommend that before being offered mammography screening, women age 75 years and older be informed of the uncertainty of benefit and potential for harm (e.g., being diagnosed with a breast cancer that would otherwise never have shown up in one's lifetime); however, few older women are informed of the risks of mammography screening and most overestimate its benefits. Objective: The aim of this study was to learn from women older than age 75 years who have predisposing risk factors for low health literacy (LHL) how they make decisions about mammography screening, whether an existing decision aid (DA) on mammography screening for them was acceptable and helpful, and suggestions for improving the DA. Methods: We conducted semi-structured interviews with 18 women who were between ages 75 and 89 years and had predisposing risk factors for LHL (i.e., answered somewhat to not at all confident to the health literacy screening question “How confident are you filling out medical forms by yourself?” and/or had an education level of some college or less). Key Results: Findings indicate that women in this study lacked knowledge and understanding that one can decide on mammography screening based on their personal values. Women were enthusiastic about screening based on an interest in taking care of themselves but rely on their providers for health care decisions. Overall, most women found the DA helpful and would recommend the use of the DA. Conclusions: Findings from this study provide formative data to test the efficacy of the modified DA in practice. Failing to consider the informational needs of adults with LHL in design of DAs could inadvertently exacerbate existing inequalities in health. It is essential that DAs consider older women's diverse backgrounds and educational levels to support their decision-making. [HLRP: Health Literacy Research and Practice. 2021;5(2):e78–e90.] Plain Language Summary: The goal of this research was to understand how women older than age 75 years with risk factors for low health literacy made decisions about getting mammograms, whether an educational pamphlet was helpful, and suggestions for improving it. This research helps in understanding how to involve this population in the process of designing patient-related materials for mammogram decision-making.
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Affiliation(s)
- Tamara Cadet
- Address correspondence to Tamara Cadet, PhD, MSW, MPH, Simmons University College of Social Sciences and Policy Practice, School of Social Work, 300 The Fenway, Boston, MA 02115;
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Freedman RA, Minami CA, Winer EP, Morrow M, Smith AK, Walter LC, Sedrak MS, Gagnon H, Perilla-Glen A, Wildiers H, Wildes TM, Lichtman SM, Loh KP, Brain EGC, Ganschow PS, Hunt KK, Mayer DK, Ruddy KJ, Jagsi R, Lin NU, Canin B, LeStage BK, Revette AC, Schonberg MA, Keating NL. Individualizing Surveillance Mammography for Older Patients After Treatment for Early-Stage Breast Cancer: Multidisciplinary Expert Panel and International Society of Geriatric Oncology Consensus Statement. JAMA Oncol 2021; 7:609-615. [PMID: 33507222 DOI: 10.1001/jamaoncol.2020.7582] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Importance There is currently no guidance on how to approach surveillance mammography for older breast cancer survivors, particularly when life expectancy is limited. Objective To develop expert consensus guidelines that facilitate tailored decision-making for routine surveillance mammography for breast cancer survivors 75 years or older. Evidence After a literature review of the risk of ipsilateral and contralateral breast cancer events among breast cancer survivors and the harms and benefits associated with mammography, a multidisciplinary expert panel was convened to develop consensus guidelines on surveillance mammography for breast cancer survivors 75 years or older. Using an iterative consensus-based approach, input from clinician focus groups, and critical review by the International Society for Geriatric Oncology, the guidelines were refined and finalized. Findings The literature review established a low risk for ipsilateral and contralateral breast cancer events in most older breast cancer survivors and summarized the benefits and harms associated with mammography. Draft mammography guidelines were iteratively evaluated by the expert panel and clinician focus groups, emphasizing a patient's risk for in-breast cancer events, age, life expectancy, and personal preferences. The final consensus guidelines recommend discontinuation of routine mammography for all breast cancer survivors when life expectancy is less than 5 years, including those with a history of high-risk cancers; consideration to discontinue mammography when life expectancy is 5 to 10 years; and continuation of mammography when life expectancy is more than 10 years. Individualized, shared decision-making is encouraged to optimally tailor recommendations after weighing the benefits and harms associated with surveillance mammography and patient preferences. The panel also recommends ongoing clinical breast examinations and diagnostic mammography to evaluate clinical findings and symptoms, with reassurance for patients that these practices will continue. Conclusions and Relevance It is anticipated that these expert guidelines will enhance clinical practice by providing a framework for individualized discussions, facilitating shared decision-making regarding surveillance mammography for breast cancer survivors 75 years or older.
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Affiliation(s)
- Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Christina A Minami
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eric P Winer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Monica Morrow
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco.,Division of Geriatrics, Veterans Affairs Health Care System, San Francisco, California
| | - Louise C Walter
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco.,Division of Geriatrics, Veterans Affairs Health Care System, San Francisco, California
| | - Mina S Sedrak
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California
| | - Haley Gagnon
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Adriana Perilla-Glen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hans Wildiers
- Department of General Medical Oncology and Multidisciplinary Breast Center, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Tanya M Wildes
- Division of Medical Oncology, Washington University School of Medicine, St Louis, Missouri
| | | | - Kah Poh Loh
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | | | - Pamela S Ganschow
- Department of Medicine, Rush University Medical College and Cook County Health, Chicago, Illinois
| | - Kelly K Hunt
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Deborah K Mayer
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill.,School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Reshma Jagsi
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor.,Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Barbara K LeStage
- Dana-Farber Cancer Institute, Boston, Massachusetts.,Alliance for Clinical Trials in Oncology, Boston, Massachusetts
| | - Anna C Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mara A Schonberg
- Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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24
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Radhakrishnan A, Wallner LP, Skolarus TA, Abrahamse PH, Kollipara AS, Katz SJ, Hawley ST. Primary Care Providers' Perceptions About Participating in Low-Risk Prostate Cancer Treatment Decisions. J Gen Intern Med 2021; 36:447-454. [PMID: 33123958 PMCID: PMC7878590 DOI: 10.1007/s11606-020-06318-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 10/14/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Primary care provider's (PCP) role in cancer care is expanding and may include supporting patients in their treatment decisions. However, the degree to which PCPs engage in this role for low-risk prostate cancer is unknown. OBJECTIVE Characterize PCP perceptions regarding their role in low-risk prostate cancer treatment decision-making. DESIGN Cross-sectional, national survey. MAIN MEASURES For men with low-risk prostate cancer, PCP reports of (1) confidence in treatment decision-making (high vs. low); (2) intended participation in key aspects of active surveillance treatment decision-making (more vs. less). KEY RESULTS A total of 347 from 741 eligible PCPs responded (adjusted response rate 56%). Half of respondent PCPs (50.3%) reported high confidence about engaging in low-risk prostate cancer treatment decision-making. The odds of PCPs reporting high confidence were greater among those in solo practice (vs working with > 1 PCP) (OR 2.18; 95% CI 1.14-4.17) and with higher volume of prostate cancer patients (> 15 vs. 6-10 in past year) (OR 2.16; 95% CI 1.02-4.61). PCP report of their intended participation in key aspects of active surveillance treatment decision-making varied: discussing worry (62.4%), reviewing benefits (48.5%) and risks (41.8%), and reviewing all treatment options (34.2%). PCPs who reported high confidence had increased odds of more participation in all aspects of active surveillance decision-making: reviewing all treatment options (OR 3.11; 95% CI 1.82-5.32), discussing worry (OR 2.12; 95% CI 1.28-3.51), and reviewing benefits (OR 3.13; 95% CI 1.89-5.16) and risks (OR 3.20; 95% CI 1.91-5.36). CONCLUSIONS The majority of PCPs were confident about engaging with patients in low-risk prostate cancer treatment decision-making, though their intended participation varied widely across four key aspects of active surveillance care. With active surveillance being considered for other low-risk cancers (such as breast and thyroid), understanding factors influencing PCP involvement will be instrumental to supporting team-based cancer care.
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Affiliation(s)
| | - Lauren P Wallner
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA
| | - Ted A Skolarus
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
- Ann Arbor VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Paul H Abrahamse
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Adam S Kollipara
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Steven J Katz
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Ann Arbor VA Center for Clinical Management Research, Ann Arbor, MI, USA
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
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Abstract
Colorectal cancer (CRC) is a common and preventable malignancy, and routine CRC screening is recommended for average risk individuals between the ages of 50 and 75 years. Screening has been shown to decrease CRC incidence and mortality. Once patients are older than 75 years, the risk to benefit ratio of ongoing screening begins to shift. As comorbidities increase and life expectancy decreases, the future potential benefits of CRC prevention become less robust, and risk for screening-related complications grows. However, firm age cutoffs are not sufficient to guide these decisions, as there is substantial physiologic heterogeneity among individuals of the same age.
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Affiliation(s)
- Andrea L Betesh
- Department of Gastroenterology and Hepatology, New York-Presbyterian Hospital/Weill Cornell Medicine, 1305 York Avenue, 4th Floor, New York, NY 10021, USA.
| | - Felice H Schnoll-Sussman
- Department of Gastroenterology and Hepatology, New York-Presbyterian Hospital/Weill Cornell Medicine, 1315 York Avenue, Ground Floor, New York, NY 10021, USA
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Kotwal AA, Walter LC. Cancer Screening in Older Adults: Individualized Decision-Making and Communication Strategies. Med Clin North Am 2020; 104:989-1006. [PMID: 33099456 PMCID: PMC7594102 DOI: 10.1016/j.mcna.2020.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cancer screening decisions in older adults can be complex due to the unclear cancer-specific mortality benefits of screening and several known harms including false positives, overdiagnosis, and procedural complications from downstream diagnostic interventions. In this review, we provide a framework for individualized cancer screening decisions among older adults, involving accounting for overall health and life expectancy, individual values, and the risks and benefits of specific cancer screening tests. We then discuss strategies for effective communication of recommendations during clinical visits that are considered more effective, easy to understand, and acceptable by older adults and clinicians.
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Affiliation(s)
- Ashwin A Kotwal
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
| | - Louise C Walter
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
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Wang T, Mott N, Miller J, Berlin NL, Hawley S, Jagsi R, Dossett LA. Patient Perspectives on Treatment Options for Older Women With Hormone Receptor-Positive Breast Cancer: A Qualitative Study. JAMA Netw Open 2020; 3:e2017129. [PMID: 32960279 PMCID: PMC7509630 DOI: 10.1001/jamanetworkopen.2020.17129] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 07/07/2020] [Indexed: 12/27/2022] Open
Abstract
Importance Women aged 70 years or older with hormone receptor-positive breast cancer have an excellent prognosis, but because of their age and comorbidities, they are at higher risk for treatment-related adverse events. Despite studies demonstrating the safety of omitting previously routine therapies, including sentinel lymph node biopsy (SLNB) and postlumpectomy radiotherapy, these treatments continue to be used at high rates. Physicians cite patient preference as one factor associated with overuse. However, little is known about how women view potential de-escalation of therapies. Objective To evaluate older women's preferences for SLNB and radiotherapy in the setting of guidelines recommending them or allowing for their omission. Design, Setting, and Participants This qualitative study was performed from October 2019 to January 2020. Midwestern women aged 70 years and older who had never received a diagnosis of breast cancer were recruited online and interviewed. Guided by an interpretive description approach, interviews were analyzed to produce a thematic description. Data analysis was performed from January to March 2020. Exposures Participants were presented with hypothetical scenarios in which they received a diagnosis of low-risk, hormone receptor-positive breast cancer and were given treatment options in accordance with current guidelines. Main Outcomes and Measures The interviews elicited perspectives on breast cancer treatment, including surgery, SLNB, chemotherapy, and postlumpectomy radiotherapy. Results The median (interquartile range) age of the 30 participants was 72.0 (71.0-76.5) years. Most of the women were White (26 participants [87%]), lived in metropolitan areas (29 participants [97%]), and were college educated (20 participants [67%] had a 4-year degree or higher). Overall, women expressed the belief that age-based guidelines were appropriate on the basis of decreased recurrence risk and increased frailty in older patients. However, many participants stated that these guidelines should not apply to healthy older women with a long life expectancy. Some participants struggled to understand that the basis for treatment de-escalation in older patients is a favorable, not poor, prognosis. Women who said they would undergo SLNB (12 participants [40%]) perceived the procedure as low risk and providing peace of mind. Most participants (22 participants [73%]) expressed a preference for omitting postlumpectomy radiotherapy because of the perceived risks, lack of benefit, and inconvenience. Conclusions and Relevance Positive reframing of the excellent prognosis driving national recommendations for de-escalation may reduce breast cancer overtreatment in older women. Strategies for reducing SLNB use will likely require education on the risks vs benefits and addressing patient preferences for peace of mind. In contrast, efforts to reduce radiotherapy use may need to address clinician or organizational factors.
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Affiliation(s)
- Ton Wang
- Department of Surgery, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Nicole Mott
- University of Michigan Medical School, Ann Arbor
| | - Jacquelyn Miller
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Nicholas L. Berlin
- Department of Surgery, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Sarah Hawley
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Reshma Jagsi
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Lesly A. Dossett
- Department of Surgery, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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Schonberg MA, Karamourtopoulos M, Jacobson AR, Aliberti GM, Pinheiro A, Smith AK, Davis RB, Schuttner LC, Hamel MB. A Strategy to Prepare Primary Care Clinicians for Discussing Stopping Cancer Screening With Adults Older Than 75 Years. Innov Aging 2020; 4:igaa027. [PMID: 32793815 PMCID: PMC7413618 DOI: 10.1093/geroni/igaa027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Indexed: 01/08/2023] Open
Abstract
Background and Objectives Adults older than 75 years are overscreened for cancer, especially those with less than 10-year life expectancy. This study aimed to learn the effects of providing primary care providers (PCPs) with scripts for discussing stopping mammography and colorectal cancer (CRC) screening and with information on patient’s 10-year life expectancy on their patients’ intentions to be screened for these cancers. Research Design and Methods Patient participants, identified via PCP appointment logs, completed a questionnaire pre- and postvisit. Primary care providers were given scripts for discussing stopping screening and information on patient’s 10-year life expectancy before these visits. Primary care providers completed a questionnaire at the end of the study. Patients and PCPs were asked about discussing stopping cancer screening and patient life expectancy. Patient screening intentions (1–15 Likert scale; lower scores suggest lower intentions) were compared pre- and postvisit using the Wilcoxon signed-rank test. Results Ninety patients older than 75 years (47% of eligible patients reached by phone) from 45 PCPs participated. Patient mean age was 80.0 years (SD = 2.9), 43 (48%) were female, and mean life expectancy was 9.7 years (SD = 2.4). Thirty-seven PCPs (12 community-based) completed a questionnaire. Primary care providers found the scripts helpful (32 [89%]) and thought they would use them frequently (29 [81%]). Primary care providers also found patient life expectancy information helpful (35 [97%]). However, only 8 PCPs (22%) reported feeling comfortable discussing patient life expectancy. Patients’ intentions to undergo CRC screening (9.0 [SD = 5.3] to 6.5 [SD = 6.0], p < .0001) and mammography screening (12.9 [SD = 3.0] to 11.7 [SD = 4.9], p = .08) decreased from pre- to postvisit (significantly for CRC). Sixty-three percent of patients (54/86) were interested in discussing life expectancy with their PCP previsit and 56% (47/84) postvisit. Discussion and Implications PCPs found scripts for discussing stopping cancer screening and information on patient life expectancy helpful. Possibly, as a result, their patients older than 75 years had lower intentions of being screened for CRC. Clinical Trials Registration Number NCT03480282
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Affiliation(s)
- Mara A Schonberg
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Alicia R Jacobson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Gianna M Aliberti
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Adlin Pinheiro
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California San Francisco
| | - Roger B Davis
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Linnaea C Schuttner
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, Washington.,Department of Medicine, University of Washington, Seattle
| | - Mary Beth Hamel
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Schonberg MA, Jacobson AR, Karamourtopoulos M, Aliberti GM, Pinheiro A, Smith AK, Schuttner LC, Park ER, Hamel MB. Scripts and Strategies for Discussing Stopping Cancer Screening with Adults > 75 Years: a Qualitative Study. J Gen Intern Med 2020; 35:2076-2083. [PMID: 32128689 PMCID: PMC7351918 DOI: 10.1007/s11606-020-05735-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 02/10/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Despite guidelines recommending not to continue cancer screening for adults > 75 years old, especially those with short life expectancy, primary care providers (PCPs) feel ill-prepared to discuss stopping screening with older adults. OBJECTIVE To develop scripts and strategies for PCPs to use to discuss stopping cancer screening with adults > 75. DESIGN Qualitative study using semi-structured interview guides to conduct individual interviews with adults > 75 years old and focus groups and/or individual interviews with PCPs. PARTICIPANTS Forty-five PCPs and 30 patients > 75 years old participated from six community or academic Boston-area primary care practices. APPROACH Participants were asked their thoughts on discussions around stopping cancer screening and to provide feedback on scripts that were iteratively revised for PCPs to use when discussing stopping mammography and colorectal cancer (CRC) screening. RESULTS Twenty-one (47%) of the 45 PCPs were community based. Nineteen (63%) of the 30 patients were female, and 13 (43%) were non-Hispanic white. PCPs reported using different approaches to discuss stopping cancer screening depending on the clinical scenario. PCPs noted it was easier to discuss stopping screening when the harms of screening clearly outweighed the benefits for a patient. In these cases, PCPs felt more comfortable being more directive. When the balance between the benefits and harms of screening was less clear, PCPs endorsed shared decision-making but found this approach more challenging because it was difficult to explain why to stop screening. While patients were generally enthusiastic about screening, they also reported not wanting to undergo tests of little value and said they would stop screening if their PCP recommended it. By the end of participant interviews, no further edits were recommended to the scripts. CONCLUSIONS To increase PCP comfort and capability to discuss stopping cancer screening with older adults, we developed scripts and strategies that PCPs may use for discussing stopping cancer screening.
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Affiliation(s)
- Mara A Schonberg
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1309 Beacon, Office 219, Brookline, MA, 02446, USA.
| | - Alicia R Jacobson
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1309 Beacon, Office 219, Brookline, MA, 02446, USA
| | - Maria Karamourtopoulos
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1309 Beacon, Office 219, Brookline, MA, 02446, USA
| | - Gianna M Aliberti
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1309 Beacon, Office 219, Brookline, MA, 02446, USA
| | - Adlin Pinheiro
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1309 Beacon, Office 219, Brookline, MA, 02446, USA
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California San Francisco, 533 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Linnaea C Schuttner
- Health Services Research & Development, VA Puget Sound Health Care System, Department of Medicine, University of Washington, Seattle, WA. 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Elyse R Park
- Department of Psychiatry, Massachusetts General Hospital, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Mary Beth Hamel
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1309 Beacon, Office 219, Brookline, MA, 02446, USA
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Smith J, Dodd RH, Hersch J, Cvejic E, McCaffery K, Jansen J. Effect of different communication strategies about stopping cancer screening on screening intention and cancer anxiety: a randomised online trial of older adults in Australia. BMJ Open 2020; 10:e034061. [PMID: 32532766 PMCID: PMC7295415 DOI: 10.1136/bmjopen-2019-034061] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To assess different strategies for communicating to older adults about stopping cancer screening. DESIGN 4 (recommendation statement about stopping screening)×(2; time) online survey-based randomised controlled trial. SETTING Australia. PARTICIPANTS 271 English-speaking participants, aged 65-90, screened for breast/prostate cancer at least once in past decade. INTERVENTIONS Time 1: participants read a scenario in which their general practitioner (GP) informed them about the potential benefits and harms of cancer screening, followed by double-blinded randomisation to one of four recommendation statements to stop screening: control ('this screening test would harm you more than benefit you'), health status ('your other health issues should take priority'), life expectancy framed positively ('this test would not help you live longer') and negatively ('you may not live long enough to benefit'). Time 2: in a follow-up scenario, the GP explained why guidelines changed over time (anchoring bias intervention). MEASURES Primary outcomes: screening intention and cancer anxiety (10-point scale, higher=greater intention/anxiety), measured at both time points. SECONDARY OUTCOMES trust (in their GP, the information provided, the Australian healthcare system), decisional conflict and knowledge of the information presented. RESULTS 271 participants' responses analysed. No main effects were found. However, screening intention was lower for the negatively framed life expectancy versus health status statement (6.0 vs 7.1, mean difference (MD)=1.1, p=0.049, 95% CI 0.0 to 2.2) in post hoc analyses. Cancer anxiety was lower for the negatively versus positively framed life expectancy statement (4.8 vs 5.8, MD=1.0, p=0.025, 95% CI 0.1 to 1.9). The anchoring bias intervention reduced screening intention (MD=0.8, p=0.044, 95% CI 0.6 to 1.0) and cancer anxiety (MD=0.3, p=0.002, 95% CI 0.1 to 0.4) across all conditions. CONCLUSION Older adults may reduce their screening intention without reporting increased cancer anxiety when clinicians use a more confronting strategy communicating they may not live long enough to benefit and add an explicit explanation why the recommendation has changed. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ACTRN12618001306202; Results).
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Affiliation(s)
- Jenna Smith
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Rachael H Dodd
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jolyn Hersch
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Erin Cvejic
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten McCaffery
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jesse Jansen
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands
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31
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Morère JF, Touboul C, Lhomel C, Rouprêt M. Dépistage du cancer de la prostate en France : résultats des enquêtes EDIFICE. Prog Urol 2020; 30:332-338. [DOI: 10.1016/j.purol.2020.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/28/2020] [Accepted: 03/06/2020] [Indexed: 12/12/2022]
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32
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Breast Cancer Screening in Older Women: The Importance of Shared Decision Making. J Am Board Fam Med 2020; 33:473-480. [PMID: 32430383 PMCID: PMC7822071 DOI: 10.3122/jabfm.2020.03.190380] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 12/29/2022] Open
Abstract
Incidence of breast cancer increases with age up until age 80. Screening mammography has demonstrated efficacy in decreasing mortality from breast cancer among women between 50 and 74 years of age. However, most major organizations do not include women over 74 in their recommendations due to the lack of evidence in this age-group. This article will review current recommendations for breast cancer screening in women over the age of 74. It will also present clear guidelines for primary care clinicians to follow that incorporate shared decision-making techniques, tools for estimating the risks and benefits of screening mammography, and strategies for integrating a patient's life expectancy and comorbidities into the decision-making process. We also emphasize the importance of using thoughtful communication strategies to fully engage older women in the breast cancer screening discussion.
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White MC, Holman DM, Goodman RA, Richardson LC. Cancer Risk Among Older Adults: Time for Cancer Prevention to Go Silver. THE GERONTOLOGIST 2019; 59:S1-S6. [PMID: 31511747 DOI: 10.1093/geront/gnz038] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Over two-thirds of all new cancers are diagnosed among adults aged ≥60 years. As the number of adults living to older ages continues to increase, so too will the number of new cancer cases. Can we do more as a society to reduce cancer risk and preserve health as adults enter their 60s, 70s, and beyond? Cancer development is a multi-step process involving a combination of factors. Each cancer risk factor represents a component of cancer causation, and opportunities to prevent cancer may exist at any time up to the final component, even years after the first. The characteristics of the community in which one lives often shape cancer risk-related behaviors and exposures over time, making communities an ideal setting for efforts to reduce cancer risk at a population level. A comprehensive approach to cancer prevention at older ages would lower exposures to known causes of cancer, promote healthy social and physical environments, expand the appropriate use of clinical preventive services, and engage older adults in these efforts. The collection of articles in this supplement provide innovative insights for exciting new directions in research and practice to expand cancer prevention efforts for older adults. This brief commentary sets the stage for the papers that follow.
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Affiliation(s)
- Mary C White
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dawn M Holman
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Richard A Goodman
- Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia
| | - Lisa C Richardson
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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Highlights From an Expert Meeting on Opportunities for Cancer Prevention Among Older Adults. THE GERONTOLOGIST 2019; 59:S94-S101. [PMID: 31100137 DOI: 10.1093/geront/gnz037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
This paper provides highlights from an expert meeting to explore opportunities to reduce cancer risk and promote health at older ages. Factors that increase cancer risk among older adults include exposure to carcinogens from multiple sources, chronic conditions such as obesity and diabetes, and unhealthy behaviors. Emerging research points to chronic social stressors - social isolation, loneliness, and financial hardship - as being linked to accelerated biological aging and increased cancer risk later in life. Older adults may disproportionately encounter these stressors as well as barriers to preventive health care services, accurate health information, and environments that promote health. Researchers can use existing cohort studies of older adults to deepen our understanding of the relative benefit of modifying specific behaviors and circumstances. The evidence points to the value of comprehensive, transdisciplinary approaches to promote health and reduce cancer risk across the entire lifespan, extending through older adulthood. Clinical encounters with older adults provide opportunities for psychosocial and behavioral screening and counseling. In the presence of multiple morbidities, preventive health services may offer greater health benefits than cancer-screening tests. Strategies that involve families and caregivers, promote positive attitudes about aging, and engage many different community sectors have the potential to prevent or delay the development of cancer at older ages.
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