Colon cancer screening in U.S. adults aged 65 and older according to life expectancy and age

Development of a Needs Assessment for Low-income Seniors in Cleveland Ohio: A student-driven Interprofessional Approach

BACKGROUND AND OBJECTIVE

Older persons with low socioeconomic status in the United States have different and unique health needs compared to younger persons. As part of a student-led, interprofessional partnership, we performed a needs assessment of community dwelling older persons with low socioeconomic status in an urban location within Ohio, USA.

METHODS

Three entities participated in the needs assessment: a student-run health clinic, a Federally Qualified Health Center, and an apartment complex of the study population. Health professional students from medical, dental, nursing, social work, nutrition, and physician assistant programs led the needs assessment process. The process consisted of multiple phases, which included preliminary literature review, survey development, data collection, and analysis. The final survey was multidisciplinary, with six content areas covered in 37 items.

RESULTS

One hundred nineteen survey responses were received, and multiple areas of need were identified including food insecurity, dental care access, and mental health. 93% of participants had at least one unmet health need and 39% of respondents met our classification for high need. The needs of the local study population had key differences from previously published data in more generalized populations of older community-dwelling individuals in the United States, notably lower utilization of dental care (43% vs. 66%), increased prevalence of possible food insecurity (30% vs. 17%), and increased use of age-appropriate preventive cancer screening services.

CONCLUSIONS

Multiple areas of need were successfully identified through a student-led interprofessional needs assessment. Future student teams can address the identified needs, again through interprofessional collaborations. This process may have unique benefits to help build robust community-academic partnerships, while fostering interprofessional collaborative opportunities among healthcare students.

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

IMPORTANCE

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

OBJECTIVE

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

DESIGN

Analysis of 2019 National Health Interview Survey.

PARTICIPANTS

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

MAIN MEASURES

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

KEY RESULTS

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

CONCLUSIONS

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

Association of Life Expectancy With Surveillance Colonoscopy Findings and Follow-up Recommendations in Older Adults

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.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Improved Survival in a Cohort of Patients Aged 75 Years and Older With Fecal Immunochemical Testing-Detected Colorectal Cancer

BACKGROUND

Fecal immunochemical testing is an accepted form of colorectal cancer screening and is recommended for adults up to the age of 75 years in Canadian guidelines. However, many individuals 75 years and older continue to receive fecal immunochemical testing despite being outside accepted guidelines.

OBJECTIVE

This study aimed to determine whether patients aged 75 years and older with screen-detected cancer demonstrated improved outcomes and survival compared with patients with non-screen-detected cancer.

DESIGN

This is a retrospective population-based cohort study.

SETTINGS

Provincial data were collected from the Alberta Cancer Registry and the Alberta Colorectal Cancer Screening Program between November 2013 and 2019.

PATIENTS

We identified an aggregated patient cohort aged 75 years and older with a diagnosis of colorectal cancer from November 2013 to November 2019, as well as patients 75 years and older who underwent fecal immunochemical testing within these dates.

MAIN OUTCOME MEASURES

The proportion of screen-detected colorectal cancers was calculated. Surgical intervention, hospital length of stay, postoperative mortality, and overall survival were analyzed.

RESULTS

Between November 2013 and 2019, 3586 patients 75 years and older were diagnosed with colorectal cancer; 690 (19%) were "screen-detected." Screen-detected patients were almost 3 times more likely to undergo surgery (OR, 2.83) and had a 36% overall survival benefit (HR, 0.64) compared with non-screen-detected patients, adjusted for other variables such as age, Charlson Comorbidity Index, and stage.

LIMITATIONS

The retrospective study design prevents conclusions regarding causation.

CONCLUSIONS

Screen detection of colorectal cancer in patients aged 75 years and older is associated with improved overall survival when controlling for other potential confounders. When compared with their non-screen-detected counterparts, these patients have an earlier stage of disease and are more likely to undergo surgical intervention with improved outcomes, irrespective of age. These data may support screening for appropriately selected patients who would otherwise fall outside of current guidelines. See Video Abstract at http://links.lww.com/DCR/B986 .

SOBREVIDA MEJORADA EN UNA COHORTE DE PACIENTES DE AOS O MS CON CNCER COLORRECTAL DETECTADOS POR RIF

ANTECEDENTES:La prueba basada en una Reacción Inmunoquímica Fecal - RIF, es una forma aceptada de detección de cáncer colorrectal y esta recomendada en adultos a partir de los 75 años en las guías canadienses. Sin embargo, muchas personas de 75 años o más continúan realizándose pruebas inmunoquímicas fecales a pesar de estar fuera de las guías aceptadas.OBJETIVO:Poder determinar si los pacientes de 75 años o más con detección RIF positiva a un cáncer demuestran mejores resultados y sobrevida comparados con los pacientes sin detección.DISEÑO:Estudio de cohortes retrospectivo basado en una población definida.CONFIGURACIÓN:Se recopilaron los datos provinciales del Registro de cánceres y del Programa de detección de cáncer colorrectal de Alberta, Canada, entre 2013 y 2019.PACIENTES:Identificamos una cohorte agregada de pacientes de 75 años o más con diagnóstico de cáncer colorrectal desde noviembre de 2013 hasta noviembre de 2019, así como pacientes de 75 años o más que se sometieron a pruebas inmunoquímicas fecales dentro de las fechas mencionadas.PRINCIPALES MEDIDAS DE RESULTADO:Se calculó la proporción de cánceres colorrectales detectados mediante un cribado. Se analizaron la intervención quirúrgica, la duración de la estadía hospitalaria, la mortalidad post-operatoria y la sobrevida global.RESULTADOS:Entre noviembre de 2013 y noviembre 2019, 3586 pacientes de 75 años o más, fueron diagnosticados con cáncer colorrectal; 690 (19%) fueron detectados por cribado. Los pacientes detectados mediante el cribado, tenían casi tres veces más probabilidades de someterse a una cirugía (Razón de Probabilidad de 2,83) y beneficiaron de una sobrevida general del 36 % (HR 0,64) comparados con los pacientes sin detectación por cribado, corregidos por otras variables como la edad, el índice de comorbilidad de Charlson y el estadío del tumor.LIMITACIONES:El diseño retrospective del presente estudio impide obtener conclusiones con respecto a la causalidad.CONCLUSIONES:La detección por cribado de cáncer colorrectal en pacientes de 75 años o más se asocia con una mejor sobrevida general cuando se controlan los otros posibles factores de confusión. Comparando con las contrapartes no detectadas por cribado, estos pacientes se encuentran en una etapa más temprana de la enfermedad y es más probable que se sometan a una intervención quirúrgica con mejores resultados, independientemente a la edad. Estos datos pueden respaldar la detección de pacientes adecuadamente seleccionados que, de otro modo, quedarían fuera de las pautas actuales. Consulte Video Resumen en http://links.lww.com/DCR/B986 . (Traducción-Dr. Xavier Delgadillo ).

Older adult preferences regarding benefits and harms of statin and aspirin therapy for cardiovascular primary prevention

Objective

Personalizing preventive therapies for atherosclerotic cardiovascular disease (ASCVD) is particularly important for older adults, as they tend to have multiple chronic conditions, increased risk for medication adverse effects, and may have heterogenous preferences when weighing health outcomes. However, little is known about outcome preferences related to ASCVD preventive therapies in older adults.

Methods

In May 2021, using an established online panel, KnowledgePanel, we surveyed older US adults aged 65-84 years without history of ASCVD on outcome preferences related to statin therapy (benefit outcomes to be reduced by the therapy: heart attack, stroke; adverse effects: diabetes, abnormal liver test, muscle pain) or aspirin therapy (benefit outcomes: heart attack, stroke; adverse effects: brain bleed, bowel bleed, stomach ulcer). We used standardized best-worst scores (range of -1 for "least worrisome" to +1 for "most worrisome") and conditional logistic regression to examine the relative importance of the outcomes.

Results

In this study, 607 ASCVD-free participants (median age 74, 46% male, 81% White) were included; 304 and 303 completed the statin and aspirin versions of the survey, respectively. For statin-related outcomes, stroke and heart attack were most worrisome (score 0.55; 95% CI 0.51, 0.60) and (0.53; 0.48, 0.58), followed by potential harms of diabetes (-0.07; -0.10, -0.03), abnormal liver test (-0.25; -0.29, -0.20), and muscle pain (-0.77; -0.82, -0.73). For aspirin-related outcomes, stroke and heart attack were similarly most worrisome (0.48; 0.43, 0.52) and (0.43; 0.38, 0.48), followed by brain bleed (0.30; 0.25, 0.34), bowel bleed (-0.31; -0.33, -0.28), and stomach ulcer (-0.90; -0.92, -0.87). Conditional logistic regression and subgroup analyses by age, sex, and race yielded similar results.

Conclusions

Older adults generally consider outcomes related to benefits of ASCVD primary preventive therapies-stroke and heart attack-more important than their adverse effects. Integrating patient preferences with risk assessment is an important next step for personalizing ASCVD preventive therapies for older adults.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPACT

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

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)

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.

All-Cause Mortality Risk Prediction in Older Adults with Cancer: Practical Approaches and Limitations

PURPOSE OF REVIEW

The prediction of all-cause mortality is an important component of shared decision-making across the cancer care continuum, particularly in older adults with limited life expectancy, for whom there is an increased risk of over-diagnosis and treatment.

RECENT FINDINGS

Currently, several international societies recommend the use of all-cause mortality risk prediction tools when making decisions regarding screening and treatment in geriatric oncology. Here, we review some practical aspects of the utilization of those tools and dissect the characteristics of those most employed in geriatric oncology, highlighting both their advantages and their limitations.

Yield of Surveillance Colonoscopy in Older Adults with a History of Polyps: A Systematic Review and Meta-Analysis

BACKGROUND

The benefit of surveillance colonoscopy in older adults is not well described.

AIMS

To quantify the detection of colorectal cancer (CRC) and advanced polyps during surveillance colonoscopy in older adults with a history of colon polyps.

METHODS

We conducted a systematic review (MEDLINE, Cochrane Library, Web of Science, and Embase) for all published studies through May 2020 in adults age > 70 undergoing surveillance colonoscopy. The main outcome was CRC and advanced polyps detection. We performed meta-analysis to pool results by age (>70 vs. 50-70).

RESULTS

The search identified 6239 studies, of which 569 underwent full-text review and 64 data abstraction, of which 19 were included. The risk of detecting CRC (N = 11) was higher in those >70 compared to 50-70 (risk ratio 1.5 (95% CI 1.1-2.2); risk difference 0.8% (95% CI -0.2%-1.8%)). Similarly, the risk of detecting advanced polyps (N = 8) was higher in those >70 compared to 50-70 (risk ratio 1.3 (95% CI 1.2-1.3), risk difference 2.7% (95% CI 1.3%-4.0%)). Most studies did not stratify results by baseline polyp risk.

CONCLUSIONS

The detection of CRC and advanced polyps during surveillance colonoscopy in older individuals was higher than in younger controls; however, the absolute risk increase for both was small. These differences must be weighed against competing medical problems and limited life expectancy in older adults when making decisions about surveillance colonoscopy. More primary data on the risks of CRC and advanced polyps accounting for number of past colonoscopies, prior polyp risk, and duration of time since last polyp are needed.

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

IMPORTANCE

Decisions for older adults (aged ≥65 years) and their clinicians about whether to continue to screen for cancer are not easy. Many older adults who are frail or have limited life expectancy or comorbidities continue to be screened for cancer despite guidelines suggesting they should not; furthermore, many older adults have limited knowledge of the potential harms of continuing to be screened.

OBJECTIVE

To summarize the patient-reported factors associated with older adults' decisions regarding screening for breast, prostate, colorectal, and cervical cancer.

EVIDENCE REVIEW

Studies were identified by searching databases from January 2000 to June 2020 and were independently assessed for inclusion by 2 authors. Data extraction and risk of bias assessment were independently conducted by 2 authors, and then all decisions were cross-checked and discussed where necessary. Data analysis was performed from September to December 2020.

FINDINGS

The search yielded 2475 records, of which 21 unique studies were included. Nine studies were quantitative, 8 were qualitative, and 4 used mixed method designs. Of the 21 studies, 17 were conducted in the US, and 10 of 21 assessed breast cancer screening decisions only. Factors associated with decision-making were synthesized into 5 categories: demographic, health and clinical, psychological, physician, and social and system. Commonly identified factors associated with the decision to undergo screening included personal or family history of cancer, positive screening attitudes, routine or habit, to gain knowledge, friends, and a physician's recommendation. Factors associated with the decision to forgo screening included being older, negative screening attitudes, and desire not to know about cancer. Some factors had varying associations, including insurance coverage, living in a nursing home, prior screening experience, health problems, limited life expectancy, perceived cancer risk, risks of screening, family, and a physician's recommendation to stop.

CONCLUSIONS AND RELEVANCE

Although guidelines suggest incorporating life expectancy and health status to inform older adults' cancer screening decisions, older adults' ingrained beliefs about screening may run counter to these concepts. Communication strategies are needed that support older adults to make informed cancer screening decisions by addressing underlying screening beliefs in context with their perceived and actual risk of developing cancer.

Sevoflurane Suppresses Colon Cancer Cell Malignancy by Regulating circ-PI4KA

Purpose

To explore the effect of SEV on colon cancer cells through circ-PI4KA.

Methods

The RNA level of circular RNA_0062389, microRNA-331-3p and LIM and SH3 protein 1 was determined by quantitative real-time polymerase chain reaction. Protein expression was detected by Western blot. Cell proliferation was investigated by 3-(4,5)-dimethylthiahiazo (-z-y1)-3,5-di-phenytetrazoliumromide, cell colony formation and 5-ethynyl-29-deoxyuridine assays. Cell apoptosis was demonstrated using Annexin V-fluorescein isothiocyanate/propidium iodide double staining assay. Cell migration and invasion were detected by transwell assay. The target relationship between miR-331-3p and circ-PI4KA or LASP1 was predicted by starBase v2.0 online database, and identified by a dual-luciferase reporter assay. The effects between SEV treatment and circ-PI4KA knockdown on tumor formation were presented by in vivo tumor formation assay.

Results

Circ-PI4KA and LASP1 expressions were dramatically upregulated, while miR-331-3p was downregulated in colon cancer tissues and cells, respectively. SEV exposure significantly decreased the expression of circ-PI4KA and LASP1, but increased miR-331-3p expression. SEV inhibited cell proliferation, migration and invasion, and induced cell apoptosis by regulating circ-PI4KA. Furthermore, circ-PI4KA interacted with miR-331-3p, and miR-331-3p interacted with LASP1. SEV inhibited tumor growth by controlling circ-PI4KA in vivo.

Conclusion

Circ-PI4KA attenuated SEV-treated colon cancer cell malignancy by upregulating LASP1 through binding to miR-331-3p, which provided a new mechanism for studying surgery-mediated therapy of colon cancer.

The role of VES-13 to identify limited life expectancy in older adults in primary healthcare settings

OBJECTIVE

To investigate the potential role of the Vulnerable Elders Survey to identify older adults with limited life expectancy in primary healthcare settings.

METHOD

This cross-sectional study was performed in all (nine) healthcare units in Jatai, Goiás (Brazil) from July to December 2018. A sample size of 407 older adults was obtained considering an older population (≥ 60 years old). Participants answered a questionnaire about sociodemographic and clinical characteristics, including the Vulnerable Elders Survey and the Suemoto index. We tested the association between limited life expectancy and the Vulnerable Elders Survey using multiple logistic regression analysis.

RESULTS

The mean age was 68.9 ± 6.6 yo, and 58.0% were women. The mean score of the Vulnerable Elders Survey was 2.0 ± 2.2, the mean score of Suemoto index was 31.5 ± 21.1%, and 17.2% had limited life expectancy. The Vulnerable Elders Survey was associated with limited life expectancy (OR = 1.57; p = < 0.0001).

CONCLUSION

The Vulnerable Elders Survey was able to identify older adults with limited life expectancy in primary healthcare settings and can play a role in detecting older adults who would not benefit from screening and strict control of chronic diseases.

Colorectal Cancer Screening in the Elderly

Colorectal cancer (CRC) is a common and preventable malignancy, and routine CRC screening is recommended for average risk individuals between the ages of 50 and 75 years. Screening has been shown to decrease CRC incidence and mortality. Once patients are older than 75 years, the risk to benefit ratio of ongoing screening begins to shift. As comorbidities increase and life expectancy decreases, the future potential benefits of CRC prevention become less robust, and risk for screening-related complications grows. However, firm age cutoffs are not sufficient to guide these decisions, as there is substantial physiologic heterogeneity among individuals of the same age.

Cancer Screening in Older Adults: Individualized Decision-Making and Communication Strategies

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.

Cancer Prevention and Screening for Older Adults: Part 1. Lung, Colorectal, Bladder, and Kidney Cancer

The incidence of most cancers increases with age. Cancer is the second most common cause of death in older adults after cardiovascular disease. Many common cancers in older adults can be prevented from occurring or can be identified at an early stage and treated effectively. The prevention and identification of cancer in its early stages, in an attempt to reduce discomfort and disability associated with advanced cancer and cancer treatment, is also a priority. Overscreening for cancer in older adults can lead to unnecessary diagnostic testing and unnecessary treatment. Both older adults and their healthcare providers need guidance on the appropriate use of cancer prevention and screening interventions. This first of a two-part review addresses special considerations regarding cancer prevention for adults aged 65 and older. Screening decisions and the impact of limited life expectancy and an older adult's ability to tolerate cancer treatment are also addressed. Guidance is provided regarding the prevention and early identification of lung, colorectal, bladder, and kidney cancer in older adults. The prevention of breast, prostate, and female urogenital cancers are addressed in Part 2. J Am Geriatr Soc 68:2399-2406, 2020.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

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

Background and Objectives

Adults older than 75 years are overscreened for cancer, especially those with less than 10-year life expectancy. This study aimed to learn the effects of providing primary care providers (PCPs) with scripts for discussing stopping mammography and colorectal cancer (CRC) screening and with information on patient’s 10-year life expectancy on their patients’ intentions to be screened for these cancers.

Research Design and Methods

Patient participants, identified via PCP appointment logs, completed a questionnaire pre- and postvisit. Primary care providers were given scripts for discussing stopping screening and information on patient’s 10-year life expectancy before these visits. Primary care providers completed a questionnaire at the end of the study. Patients and PCPs were asked about discussing stopping cancer screening and patient life expectancy. Patient screening intentions (1–15 Likert scale; lower scores suggest lower intentions) were compared pre- and postvisit using the Wilcoxon signed-rank test.

Results

Ninety patients older than 75 years (47% of eligible patients reached by phone) from 45 PCPs participated. Patient mean age was 80.0 years (SD = 2.9), 43 (48%) were female, and mean life expectancy was 9.7 years (SD = 2.4). Thirty-seven PCPs (12 community-based) completed a questionnaire. Primary care providers found the scripts helpful (32 [89%]) and thought they would use them frequently (29 [81%]). Primary care providers also found patient life expectancy information helpful (35 [97%]). However, only 8 PCPs (22%) reported feeling comfortable discussing patient life expectancy. Patients’ intentions to undergo CRC screening (9.0 [SD = 5.3] to 6.5 [SD = 6.0], p < .0001) and mammography screening (12.9 [SD = 3.0] to 11.7 [SD = 4.9], p = .08) decreased from pre- to postvisit (significantly for CRC). Sixty-three percent of patients (54/86) were interested in discussing life expectancy with their PCP previsit and 56% (47/84) postvisit.

Discussion and Implications

PCPs found scripts for discussing stopping cancer screening and information on patient life expectancy helpful. Possibly, as a result, their patients older than 75 years had lower intentions of being screened for CRC.

Clinical Trials Registration Number

NCT03480282

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

BACKGROUND

Despite guidelines recommending not to continue cancer screening for adults > 75 years old, especially those with short life expectancy, primary care providers (PCPs) feel ill-prepared to discuss stopping screening with older adults.

OBJECTIVE

To develop scripts and strategies for PCPs to use to discuss stopping cancer screening with adults > 75.

DESIGN

Qualitative study using semi-structured interview guides to conduct individual interviews with adults > 75 years old and focus groups and/or individual interviews with PCPs.

PARTICIPANTS

Forty-five PCPs and 30 patients > 75 years old participated from six community or academic Boston-area primary care practices.

APPROACH

Participants were asked their thoughts on discussions around stopping cancer screening and to provide feedback on scripts that were iteratively revised for PCPs to use when discussing stopping mammography and colorectal cancer (CRC) screening.

RESULTS

Twenty-one (47%) of the 45 PCPs were community based. Nineteen (63%) of the 30 patients were female, and 13 (43%) were non-Hispanic white. PCPs reported using different approaches to discuss stopping cancer screening depending on the clinical scenario. PCPs noted it was easier to discuss stopping screening when the harms of screening clearly outweighed the benefits for a patient. In these cases, PCPs felt more comfortable being more directive. When the balance between the benefits and harms of screening was less clear, PCPs endorsed shared decision-making but found this approach more challenging because it was difficult to explain why to stop screening. While patients were generally enthusiastic about screening, they also reported not wanting to undergo tests of little value and said they would stop screening if their PCP recommended it. By the end of participant interviews, no further edits were recommended to the scripts.

CONCLUSIONS

To increase PCP comfort and capability to discuss stopping cancer screening with older adults, we developed scripts and strategies that PCPs may use for discussing stopping cancer screening.

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

IMPORTANCE

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

Clinician Perspectives on Overscreening for Cancer in Older Adults With Limited Life Expectancy

BACKGROUND/OBJECTIVES

Guidelines recommend against routine screening for breast, colorectal, and prostate cancers in older adults with less than 10 years of life expectancy. However, clinicians often continue to recommend cancer screening for these patients. We examined primary care clinicians' perspectives regarding overscreening, as defined by limited life expectancy.

DESIGN

Semistructured, in-depth individual interviews.

SETTING

Twenty-one academic and nonacademic primary care clinics in Maryland.

PARTICIPANTS

Thirty primary care clinicians from internal medicine, family medicine, medicine/pediatrics, and geriatric medicine.

MEASUREMENTS

Interviews explored whether the clinicians believed that overscreening for breast, colorectal, or prostate cancers existed in older adults and their views on using life expectancy to decide on stopping routine screening. Audio recordings of the interviews were transcribed verbatim. Two investigators independently coded all transcripts using qualitative content analysis.

RESULTS

Most clinicians were physicians (24/30) and women (16/30). Content analysis generated three major themes. (1) Many, but not all, clinicians perceived overscreening in older adults as a problem. (2) There was controversy around using limited life expectancy to define overscreening due to concerns that the guidelines did not capture potential nonmortality benefits of screening; that population-based screening data could not be easily applied to individuals; that this approach failed to account for patient choice; and that life expectancy predictions were inaccurate. (3) Some clinicians worried that using life expectancy to define overscreening may inadvertently introduce bias and lead to unintended harms.

CONCLUSIONS

Several clinicians disagreed with guideline frameworks of using limited life expectancy to guide cancer screening cessation. Some disagreement stems from inadequate knowledge about the benefits and harms of cancer screening and indicates a need for education or decision support. Other reasons for disagreement highlight the need to refine the current recommended cancer screening approaches and identify strategies to avoid unintended consequences, such as introducing bias or exacerbating existing disparities. J Am Geriatr Soc 68:1462-1468, 2020.

A Brief Review of Nutraceutical Ingredients in Gastrointestinal Disorders: Evidence and Suggestions

The dietary effect on gut health has long been recognized through the empirical practice of soothing gastric discomfort with certain types of food, and recently the correlation between specific diets with lower incidences of several gastrointestinal diseases has been revealed. Ingredients from those considered beneficial foods have been isolated and studied, and some of them have already been put into the supplement market. In this review, we focus on latest studies of these food-derived ingredients for their proposed preventive and therapeutic roles in gastrointestinal disorders, with the attempt of drawing evidence-based suggestions on consuming these products.

Examining Generalizability of Older Adults' Preferences for Discussing Cessation of Screening Colonoscopies in Older Adults with Low Health Literacy

BACKGROUND/OBJECTIVES

Many older adults receive unnecessary screening colonoscopies. We previously conducted a survey using a national online panel to assess older adults' preferences for how clinicians can discuss stopping screening colonoscopies. We sought to assess the generalizability of those results by comparing them to a sample of older adults with low health literacy.

DESIGN

Cross-sectional survey.

SETTING

Baltimore metropolitan area (low health literacy sample) and a national, probability-based online panel-KnowledgePanel (national sample).

PARTICIPANTS

Adults 65+ with low health literacy measured using a single-question screen (low health literacy sample, n = 113) and KnowledgePanel members 65+ who completed survey about colorectal cancer screening (national sample, n = 441).

MEASUREMENTS

The same survey was administered to both groups. Using the best-worst scaling method, we assessed relative preferences for 13 different ways to explain stopping screening colonoscopies. We used conditional logistic regression to quantify the relative preference for each explanation, where a higher preference weight indicates stronger preference. We analyzed each sample separately, then compared the two samples using Spearman's correlation coefficient, the likelihood ratio test to assess for overall differences between the two sets of preference weights, and the Wald test to assess differences in preference weights for each individual phrases.

RESULTS

The responses from the two samples were highly correlated (Spearman's coefficient 0.92, p < 0.0001). The most preferred phrase to explain stopping screening colonoscopy was "Your other health issues should take priority" in both groups. The three least preferred options were also the same for both groups, with the least preferred being "The doctor does not give an explanation." The explanation that referred to "quality of life" was more preferred by the low health literacy group whereas explanations that mentioned "unlikely to benefit" and "high risk for harms" were more preferred by the national survey group (all p < 0.001).

CONCLUSION

Among two different populations of older adults with different health literacy levels, the preferred strategies for clinicians to discuss stopping screening colonoscopies were highly correlated. Our results can inform effective communication about stopping screening colonoscopies in older adults across different health literacy levels.

Approaches to Risk Assessment Among Older Patients With Diabetes

PURPOSE OF REVIEW

A patient's prognosis and risk of adverse drug effects are important considerations for individualizing care of older patients with diabetes. This review summarizes the evidence for risk assessment and proposes approaches for clinicians in the context of current clinical guidelines.

RECENT FINDINGS

Diabetes guidelines vary in their recommendations for how life expectancy should be estimated and used to inform the selection of glycemic targets. Readily available prognostic tools may improve estimation of life expectancy but require validation among patients with diabetes. Treatment decisions based on prognosis are difficult for clinicians to communicate and for patients to understand. Determining hypoglycemia risk involves assessing major risk factors; models to synthesize these factors have been developed. Applying risk assessment to individualize diabetes care is complex and currently relies heavily on clinician judgment. More research is need to validate structured approaches to risk assessment and determine how to incorporate them into patient-centered diabetes care.

How Do Older Adults Consider Age, Life Expectancy, Quality of Life, and Physician Recommendations When Making Cancer Screening Decisions? Results from a National Survey Using a Discrete Choice Experiment

Background. Older adults with limited life expectancy frequently receive cancer screening, although on average, harms outweigh benefits. We examined the influence of life expectancy on older adults' cancer screening decisions relative to three other factors. Methods. Adults aged 65+ years (N = 1272) were recruited from a national online survey panel. Using a discrete choice experiment, we systematically varied a hypothetical patient's life expectancy, age, quality of life, and physician's recommendation and asked whether the participant would choose screening. Participants were randomized to questions about colonoscopy or prostate-specific antigen/mammography screenings. Logistic regression produced preference weights that quantified the relative influence of the 4 factors on screening decisions. Results. 879 older adults completed the survey, 660 of whom varied their screening choices in response to the 4 factors we tested. The age of the hypothetical patient had the largest influence on choosing screening: the effect of age being 65 versus 85 years had a preference weight of 2.44 (95% confidence interval [CI]: 2.22, 2.65). Life expectancy (10 versus 1 year) had the second largest influence (preference weight: 1.64, CI: 1.41, 1.87). Physician recommendation (screen versus do not screen) and quality of life (good versus poor) were less influential, with preference weights of 0.90 (CI: 0.72, 1.08) and 0.68 (CI: 0.52, 0.83), respectively. Conclusions. While clinical practice guidelines increasingly use life expectancy in addition to age to guide screening decisions, we find that age is the most influential factor, independent of life expectancy, quality of life, and physician recommendation, in older adults' cancer screening choices. Strategies to reduce overscreening should consider the importance patients give to continuing screening at younger ages, even when life expectancy is limited.

Communicating About Stopping Cancer Screening: Comparing Clinicians' and Older Adults' Perspectives

BACKGROUND AND OBJECTIVES

Older adults with limited life expectancy frequently receive cancer screening. We sought to compare the perspectives of clinicians and older adults on how to communicate about stopping cancer screening.

RESEARCH DESIGN AND METHODS

We used data from two studies involving semistructured in-person individual interviews, in which we asked about perspectives on communication about stopping cancer screening, with 28 primary care clinicians and 40 community-dwelling older adults, respectively.

RESULTS

We identified three major themes: (a) Consensus among primary care clinicians and older adults regarding communication around stopping cancer screening. Both groups considered discussing the benefits/risks of cancer screening and involving patients in the decision as important and mentioned framing screening cessation as shift in health priorities. (b) Differences in perceived reactions to stopping cancer screening. Primary care clinicians were concerned about patient reaction to stopping cancer screening, whereas older adults reported no negative reactions in the context of a trusting relationship. (c) Differences in views around whether to discuss life expectancy in the context of stopping cancer screening. Clinicians rarely discussed life expectancy in this context, whereas older adults were divided on whether life expectancy should be discussed.

DISCUSSION AND IMPLICATIONS

Given the heterogeneity in older adults' preferences, it is important to assess whether patients want to discuss life expectancy when discussing stopping cancer screening, though use of the specific term "life expectancy" may not be necessary. Instead, focusing discussion on the benefits/risks of cancer screening and mentioning shift in health priorities are acceptable communication strategies for both clinicians and older adults.

Influence of Age, Health, and Function on Cancer Screening in Older Adults with Limited Life Expectancy

BACKGROUND/OBJECTIVES

We examined the relationship between cancer screening and life expectancy predictors, focusing on the influence of age versus health and function, in older adults with limited life expectancy.

DESIGN

Longitudinal cohort study SETTING: National Health and Aging Trends Study (NHATS) with linked Medicare claims.

PARTICIPANTS

Three cohorts of adults 65+ enrolled in fee-for-service Medicare were constructed: women eligible for breast cancer screening (n = 2043); men eligible for prostate cancer screening (n = 1287); men and women eligible for colorectal cancer screening (n = 3759).

MEASUREMENTS

We assessed 10-year mortality risk using 2011 NHATS data, then used claims data to assess 2-year prostate and breast cancer screening rates and 3-year colorectal cancer screening rates. Among those with limited life expectancy (10-year mortality risk > 50%), we stratified participants at each level of predicted mortality risk and split participants in each risk stratum by the median age. We assembled two sub-groups from these strata that were matched on predicted life expectancy: a "younger sub-group" with relatively poorer health/functional status and an "older sub-group" with relatively better health/functional status. We compared screening rates between sub-groups.

RESULTS

For all three cancer screenings, the younger sub-groups (average ages 73.4-76.1) had higher screening rates than the older sub-groups (average ages 83.6-86.9); screening rates were 42.9% versus 34.2% for prostate cancer screening (p = 0.02), 33.6% versus 20.6% for breast cancer screening (p < 0.001), 13.1% versus 6.7% for colorectal cancer screening in women (p = 0.006), and 20.5% versus 12.1% for colorectal cancer screening in men (p = 0.002).

CONCLUSION

Among older adults with limited life expectancy, those who are relatively younger with poorer health and functional status are over-screened for cancer at higher rates than those who are older with the same predicted life expectancy.

Cancer Screening in the Elderly: A Review of Breast, Colorectal, Lung, and Prostate Cancer Screening

There are relatively limited data on outcomes of screening older adults for cancer; therefore, the decision to screen older adults requires balancing the potential harms of screening and follow-up diagnostic tests with the possibility of benefit. Harms of screening can be amplified in older and frail adults and include discomfort from undergoing the test itself, anxiety, potential complications from diagnostic procedures resulting from a false-positive test, false reassurance from a false-negative test, and overdiagnosis of tumors that are of no threat and may result in overtreatment. In this paper, we review the evidence and guidelines on breast, colorectal, lung and prostate cancer as applied to older adults. We also provide a general framework for approaching cancer screening in older adults by incorporating evidence-based guidelines, patient preferences, and patient life expectancy estimates into shared screening decisions.

Perceived Life Expectancy Is Associated with Colorectal Cancer Screening in England

Background

Cancer screening is a behavior that represents investment in future health. Such investment may depend on how much ‘future’ a person expects.

Purpose

The purpose of this study was to investigate the prospective association between perceived personal life expectancy and participation in fecal occult blood test screening for colorectal cancer (CRC) in a national program.

Methods

Data were from interviews with 3975 men and women in the English Longitudinal Study of Ageing (ELSA) within the eligible age range for the national screening program (60 to 74 years). Perceived life expectancy was indexed as the individual’s estimate of their chance of living another 10–15 years (exact time varied by age), assessed in 2008/2009. Participation in CRC screening from 2010 to 2012/2013 was assessed in 2012/2013. Logistic regression was used to estimate the association between perceived life expectancy and screening participation, adjusted for numeracy and known mortality risk factors.

Results

Overall, 71% of respondents (2817/3975) reported completing at least one fecal occult blood test (FOBt) during the follow-up. Screening uptake was 76% (1272/1683) among those who estimated their 10–15-year life expectancy as 75–100%, compared with 52% (126/243) among those who estimated theirs as 0–25% (adjusted OR 1.74, 95% CI 1.29–2.34).

Conclusions

A longer perceived life expectancy is associated with greater likelihood of participating in CRC screening in England. However, half of people with a low perceived life expectancy still participated in screening. Given that CRC screening is recommended for adults with a remaining life expectancy of ≥10 years, future research should investigate how to communicate the aims of screening more effectively.

Use of Surveillance Mammography Among Older Breast Cancer Survivors by Life Expectancy

Purpose The benefits of annual surveillance mammography in older breast cancer survivors with limited life expectancy are not known, and there are important risks; however, little is known about mammography use among these women. Materials and Methods We used National Health Interview Study data from 2000, 2005, 2008, 2010, 2013, and 2015 to examine surveillance mammography use among women age ≥ 65 years who reported a history of breast cancer. Using multivariable logistic regression, we assessed the probability of mammography within the last 12 months by 5- and 10-year life expectancy (using the validated Schonberg index), adjusting for survey year, region, age, marital status, insurance, educational attainment, and indicators of access to care. Results Of 1,040 respondents, 33.7% were age ≥ 80 years and 88.6% were white. Approximately 8.6% and 35.1% had an estimated life expectancy of ≤ 5 and ≤ 10 years, respectively. Overall, 78.9% reported having routine surveillance mammography in the last 12 months. Receipt of mammography decreased with decreasing life expectancy ( P < .001), although 56.7% and 65.9% of those with estimated ≤ 5-year and ≤ 10-year life expectancy, respectively, reported mammography in the last year. Conversely, 14.1% of those with life expectancy > 10 years did not report mammography. In adjusted analyses, lower ( v higher) life expectancy was significantly associated with lower odds of mammography (odds ratio, 0.4; 95% CI, 0.3 to 0.8 for ≤ 5-year life expectancy and OR, 0.4; 95% CI, 0.3 to 0.6 for ≤ 10-year life expectancy). Conclusion Many (57%) older breast cancer survivors with an estimated short life expectancy (< 5 years) receive annual surveillance mammography despite unknown benefits, whereas 14% with estimated life expectancy > 10 years did not report mammography. Practice guidelines are needed to optimize and tailor follow-up care for older patients.

Cancer Screening of Older Adults in Israel According to Life Expectancy: Cross Sectional Study

OBJECTIVES

To examine over-screening of older Israelis for colon and breast cancer.

DESIGN

Cross sectional.

SETTING

Clalit Health Services (CHS), Israel's largest health maintenance organization (HMO), provides care for more than half of the country's population and operates a national age-based programs for cancer screening.

PARTICIPANTS

All community-dwelling members aged 65 to 79 in 2014 (N = 370,876).

MEASUREMENTS

We used CHS data warehouse to evaluate cancer screening during 2014. Life expectancy (LE) was estimated using the validated Schonberg index.

RESULTS

Almost one-quarter (23.1%; 15.6% of adults aged 65-74, 42.7% of adults aged 75-79) of the study population had an estimated LE of less than 10 years. Annual fecal occult blood test and biannual mammography rates among adults aged 65 to 74 with a LE of 10 years or longer were 37.1% and 70.0%, respectively. Rates dropped after age 75 (4.0%, 19.5%) and to a lesser extent with a LE of less than 10 years (31.6%, 56.4%). Prostate-specific antigen testing is not part of the national screening program, and the proportion of people tested (42.6%), did not vary similarly with age of 75 and older (43.2%) or LE of less than 10 years (38.1%).

CONCLUSION

The cancer screening inclusion criteria of the national referral system have a strong effect on receipt of screening; LE considerations are less influential. Some method of estimating LE could be incorporated into algorithms to improve individualized cancer screening to reduce over- and underscreening of older adults.

Older Adults' Views and Communication Preferences About Cancer Screening Cessation

IMPORTANCE

Older adults with limited life expectancy are frequently screened for cancer even though it exposes them to risks of screening with minimal benefit. Patient preferences may be an important contributor to continued screening.

OBJECTIVE

To examine older adults' views on the decision to stop cancer screening when life expectancy is limited and to identify older adults' preferences for how clinicians should communicate recommendations to cease cancer screening.

DESIGN, SETTING, AND PARTICIPANTS

In this semistructured interview study, we interviewed 40 community-dwelling older adults (≥ 65 years) recruited at 4 clinical programs affiliated with an urban academic medical center.

MAIN OUTCOMES AND MEASURE

We transcribed the audio recorded discussions and analyzed the transcripts using standard techniques of qualitative content analysis to identify major themes and subthemes.

RESULTS

The participants' average age was 75.7 years. Twenty-three participants (57.5%) were female; 25 (62.5%) were white. Estimated life expectancy was less than 10 years for 19 participants (47.5%). We identified 3 key themes. First, participants were amenable to stopping cancer screening, especially in the context of a trusting relationship with their clinician. Second, although many participants supported using age and health status to individualize the screening decision, they did not often understand the role of life expectancy. All except 2 participants objected to a Choosing Wisely statement about not recommending cancer screening in those with limited life expectancy, often believing that clinicians cannot accurately predict life expectancy. Third, participants preferred that clinicians explain a recommendation to stop screening by incorporating individual health status but were divided on whether life expectancy should be mentioned. Specific wording of life expectancy was important; many felt the language of "you may not live long enough to benefit from this test" was unnecessarily harsh compared with the more positive messaging of "this test would not help you live longer."

CONCLUSIONS AND RELEVANCE

Although research and clinical practice guidelines recommend using life expectancy to inform cancer screening, older adults may not consider life expectancy important in screening and may not prefer to hear about life expectancy when discussing screening. The described communication preferences can help inform future screening discussions. Better delineating patient-centered approaches to discuss screening cessation is an important step toward optimizing cancer screening in older adults.

Cancer Screening in Older Adults

When screening for cancer in older adults, it is important to consider the risks of screening, how long it takes to benefit from screening, and the patient's comorbidities and life expectancy. Delivering high-value care requires the consideration of evidence-based screening guidelines and careful selection of patients. This article considers the impact of cancer. It explores perspectives on the costs of common cancer screening tests, illustrates how using life expectancy can help clinicians determine who will benefit most from screening, and provides tools to help clinicians discuss with their older patients when it may be appropriate to stop screening for cancer.

Assessing Colorectal Cancer Screening Adherence of Medicare Fee-for-Service Beneficiaries Age 76 to 95 Years

INTRODUCTION

There are concerns about potential overuse of colorectal cancer (CRC) screening services among average-risk individuals older than age 75 years.

MATERIALS AND METHODS

Using a 5% random noncancer sample of Medicare beneficiaries who resided in the SEER areas, we examined rates of CRC screening adherence, defined by the Medicare coverage policy, among average-risk fee-for-service beneficiaries age 76 to 95 years from 2002 to 2010. The two outcomes are the status of overall CRC screening adherence, and the status of adherence to colonoscopy (v other modalities) conditional on patient adherence.

RESULTS

Overall CRC screening adherence rates of Medicare beneficiaries age 76 to 95 years increased from 13.0% to 21.4% from 2002 to 2010. In 2002, 2.2% of beneficiaries were adherent to colonoscopy, and 10.7%, by other modalities; the corresponding rates were 19.5% and 1.9%, respectively, in 2010. Specifically, rates of adherence to colonoscopy were 1.1% for those age 86 to 90 years and almost nil for those age 91 to 95 years in 2002, but the rates became 13.5% and 8.2%, respectively, in 2010. Compared with white beneficiaries, black beneficiaries age 76 to 95 years had a 7-percentage-point lower adherence rate. However, overall adherence rates among blacks increased by 168.6% from 2002 to 2010, whereas rates among whites increased by 63.0%. Logistic regressions showed that blacks age 86 to 95 years were less likely than whites to be adherent (odds ratio, 0.56; 95% CI, 0.47 to 0.59) but were more likely to be adherent to colonoscopy (odds ratio, 2.34; 95% CI, 1.47 to 3.91).

CONCLUSION

High proportions of average-risk Medicare fee-for-service beneficiaries screened by colonoscopy may represent opportunities for improving appropriateness and allocative efficiency of CRC screening by Medicare.

Primary Care Practitioners' Views on Incorporating Long-term Prognosis in the Care of Older Adults

IMPORTANCE

Clinical practice recommendations increasingly advocate that older patients' life expectancy be considered to inform a number of clinical decisions. It is not clear how primary care practitioners approach these recommendations in their clinical practice.

OBJECTIVE

To explore the range of perspectives from primary care practitioners on long-term prognosis, defined as prognosis regarding life expectancy in the range of years, in their care of older adults.

DESIGN, SETTING, AND PARTICIPANTS

A qualitative, semistructured interview study was conducted in a large group practice with multiple sites in rural, urban, and suburban settings. Twenty-eight primary care practitioners were interviewed; 20 of these participants (71%) reported that at least 25% of their patient panel was older adults. The audiorecorded discussions were transcribed and analyzed, using qualitative content analysis to identify major themes and subthemes. The study was conducted between January 30 and May 13, 2015. Data analysis was performed between June 10 and September 1, 2015.

MAIN OUTCOMES AND MEASURES

The constant comparative approach was used to qualitatively analyze the content of the transcripts.

RESULTS

Of the 28 participants, 16 were women and 21 were white; the mean (SD) age was 46.2 (10.3) years. Twenty-six were physicians and 2 were nurse practitioners. Their time since completing clinical training was 16.0 (11.4) years. These primary care practitioners reported considering life expectancy, often in the range of 5 to 10 years, in several clinical scenarios in the care of older adults, but balanced the prognosis consideration against various other factors in decision making. In particular, patient age was found to modulate how prognosis affects the primary care practitioners' decision making, with significant reluctance among them to cease preventive care that has a long lag time to achieve benefit in younger patients despite limited life expectancy. The participants assessed life expectancy based on clinical experience rather than using validated tools and varied widely in their prognostication time frame, from 2 years to 30 years. Participants often considered prognosis without explicitly discussing it with patients and disagreed on whether and when long-term prognosis needs to be specifically discussed. The participants identified numerous barriers to incorporating prognosis in the care of older adults including uncertainty in predicting prognosis, difficulty in discussing prognosis, and concern about patient reactions.

CONCLUSIONS AND RELEVANCE

Despite clinical recommendations to increasingly incorporate patients' long-term prognosis in clinical decisions, primary care practitioners encounter several barriers and ambiguities in the implementation of these recommendations.

The Evolution of Gero-Oncology Nursing

OBJECTIVES

This article summarizes the evolution of gero-oncology nursing and highlights key educational initiatives, clinical practice issues, and research areas to enhance care of older adults with cancer.

DATA SOURCES

Peer-reviewed literature, position statements, clinical practice guidelines, Web-based materials, and professional organizations' resources.

CONCLUSION

Globally, the older adult cancer population is rapidly growing. The care of older adults with cancer requires an understanding of their diverse needs and the intersection of cancer and aging. Despite efforts to enhance competence in gero-oncology and to develop a body of evidence, nurses and health care systems remain under-prepared to provide high-quality care for older adults with cancer.

IMPLICATIONS FOR NURSING PRACTICE

Nurses must take a leadership role in integrating gerontological principles into oncology settings. Working closely with interdisciplinary team members, nurses should utilize available resources and continue to build evidence through gero-oncology nursing research.