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Smith RE, Sprague BL, Henderson LM, Kerlikowske K, Miglioretti DL, Wernli KJ, Onega T, diFlorio-Alexander RM, Tosteson ANA. Breast density knowledge and willingness to delay treatment for pre-operative breast cancer imaging among women with a personal history of breast cancer. Breast Cancer Res 2024; 26:73. [PMID: 38685119 PMCID: PMC11057127 DOI: 10.1186/s13058-024-01820-x] [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: 12/04/2023] [Accepted: 04/04/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Following a breast cancer diagnosis, it is uncertain whether women's breast density knowledge influences their willingness to undergo pre-operative imaging to detect additional cancer in their breasts. We evaluated women's breast density knowledge and their willingness to delay treatment for pre-operative testing. METHODS We surveyed women identified in the Breast Cancer Surveillance Consortium aged ≥ 18 years, with first breast cancer diagnosed within the prior 6-18 months, who had at least one breast density measurement within the 5 years prior to their diagnosis. We assessed women's breast density knowledge and correlates of willingness to delay treatment for 6 or more weeks for pre-operative imaging via logistic regression. RESULTS Survey participation was 28.3% (969/3,430). Seventy-two percent (469/647) of women with dense and 11% (34/322) with non-dense breasts correctly knew their density (p < 0.001); 69% (665/969) of all women knew dense breasts make it harder to detect cancers on a mammogram; and 29% (285/969) were willing to delay treatment ≥ 6 weeks to undergo pre-operative imaging. Willingness to delay treatment did not differ by self-reported density (OR:0.99 for non-dense vs. dense; 95%CI: 0.50-1.96). Treatment with chemotherapy was associated with less willingness to delay treatment (OR:0.67; 95%CI: 0.46-0.96). Having previously delayed breast cancer treatment more than 3 months was associated with an increased willingness to delay treatment for pre-operative imaging (OR:2.18; 95%CI: 1.26-3.77). CONCLUSIONS Understanding of personal breast density was not associated with willingness to delay treatment 6 or more weeks for pre-operative imaging, but aspects of a woman's treatment experience were. CLINICALTRIALS GOV : NCT02980848 registered December 2, 2016.
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Affiliation(s)
- Rebecca E Smith
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, 1 Medical Center Dr. WTRB Level 5, Hinman Box 7251, NH 03756, Lebanon, NH, USA.
| | - Brian L Sprague
- Department of Surgery, University of Vermont Cancer Center, University of Vermont, Burlington, VT, USA
| | - Louise M Henderson
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Karla Kerlikowske
- Departments of Medicine, and Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Diana L Miglioretti
- Department of Public Health Sciences, University of California, Davis, CA, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Karen J Wernli
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Tracy Onega
- Department of Population Health Science, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Roberta M diFlorio-Alexander
- Radiology Department, Dartmouth Health and Geisel School of Medicine at Dartmouth Lebanon, Lebanon, NH, USA
- Dartmouth Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, 1 Medical Center Dr. WTRB Level 5, Hinman Box 7251, NH 03756, Lebanon, NH, USA
- Dartmouth Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, 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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Pilla SJ, Meza KA, Schoenborn NL, Boyd CM, Maruthur NM, Chander G. A Qualitative Study of Perspectives of Older Adults on Deintensifying Diabetes Medications. J Gen Intern Med 2023; 38:1008-1015. [PMID: 36175758 PMCID: PMC10039184 DOI: 10.1007/s11606-022-07828-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/16/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND While many older adults with type 2 diabetes have tight glycemic control beyond guideline-recommended targets, deintensifying (stopping or dose-reducing) diabetes medications rarely occurs. OBJECTIVE To explore the perspectives of older adults with type 2 diabetes around deintensifying diabetes medications. DESIGN This qualitative study used individual semi-structured interviews, which included three clinical scenarios where deintensification may be indicated. PARTICIPANTS Twenty-four adults aged ≥65 years with medication-treated type 2 diabetes and hemoglobin A1c <7.5% were included (to thematic saturation) using a maximal variation sampling strategy for diabetes treatment and physician specialty. APPROACH Interviews were independently coded by two investigators and analyzed using a grounded theory approach. We identified major themes and subthemes and coded responses to the clinical scenarios as positive (in favor of deintensification), negative, or ambiguous. KEY RESULTS Participants' mean age was 74 years, half were women, and 58% used a sulfonylurea or insulin. The first of four major themes was fear of losing control of diabetes, which participants weighed against the benefits of taking less medication (Theme 2). Few participants viewed glycemic control below target as a reason for deintensification and a majority would restart the medication if their home glucose increased. Some participants were anchored to their current diabetes treatment (Theme 3) driven by unrealistic views of medication benefits. A trusting patient-provider relationship (Theme 4) was a positive influence. In clinical scenarios, 8%, 4%, and 75% of participants viewed deintensification positively in the setting of poor health, limited life expectancy, and high hypoglycemia risk, respectively. CONCLUSIONS Optimizing deintensification requires patient education that describes both individualized glycemic targets and how they will change over the lifespan. Deintensification is an opportunity for shared decision-making, but providers must understand patients' beliefs about their medications and address misconceptions. Hypoglycemia prevention may be a helpful framing for discussing deintensification.
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Affiliation(s)
- Scott J Pilla
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Kayla A Meza
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nancy L Schoenborn
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cynthia M Boyd
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nisa M Maruthur
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Geetanjali Chander
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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4
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Sepucha K, Han PKJ, Chang Y, Atlas SJ, Korsen N, Leavitt L, Lee V, Percac-Lima S, Mancini B, Richter J, Scharnetzki E, Siegel LC, Valentine KD, Fairfield KM, Simmons LH. Promoting Informed Decisions About Colorectal Cancer Screening in Older Adults (PRIMED Study): a Physician Cluster Randomized Trial. J Gen Intern Med 2023; 38:406-413. [PMID: 35931908 PMCID: PMC9362387 DOI: 10.1007/s11606-022-07738-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 07/01/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND For adults aged 76-85, guidelines recommend individualizing decision-making about whether to continue colorectal cancer (CRC) testing. These conversations can be challenging as they need to consider a patient's CRC risk, life expectancy, and preferences. OBJECTIVE To promote shared decision-making (SDM) for CRC testing decisions for older adults. DESIGN Two-arm, multi-site cluster randomized trial, assigning physicians to Intervention and Comparator arms. Patients were surveyed shortly after the visit to assess outcomes. Analyses were intention-to-treat. PARTICIPANTS AND SETTING Primary care physicians affiliated with 5 academic and community hospital networks and their patients aged 76-85 who were due for CRC testing and had a visit during the study period. INTERVENTIONS Intervention arm physicians completed a 2-h online course in SDM communication skills and received an electronic reminder of patients eligible for CRC testing shortly before the visit. Comparator arm received reminders only. MAIN MEASURES The primary outcome was patient-reported SDM Process score (range 0-4 with higher scores indicating more SDM); secondary outcomes included patient-reported discussion of CRC screening, knowledge, intention, and satisfaction with the visit. KEY RESULTS Sixty-seven physicians (Intervention n=34 and Comparator n=33) enrolled. Patient participants (n=466) were on average 79 years old, 50% with excellent or very good self-rated overall health, and 66% had one or more prior colonoscopies. Patients in the Intervention arm had higher SDM Process scores (adjusted mean difference 0.36 (95%CI (0.08, 0.64), p=0.01) than in the Comparator arm. More patients in the Intervention arm reported discussing CRC screening during the visit (72% vs. 60%, p=0.03) and had higher intention to follow through with their preferred approach (58.0% vs. 47.1, p=0.03). Knowledge scores and visit satisfaction did not differ significantly between arms. CONCLUSION Physician training plus reminders were effective in increasing SDM and frequency of CRC testing discussions in an age group where SDM is essential. TRIAL REGISTRATION The trial is registered on clinicaltrials.gov (NCT03959696).
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Affiliation(s)
- Karen Sepucha
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Paul K J Han
- Center for Interdisciplinary Population and Health Research, Maine Medical Center, Portland, ME, USA
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, USA
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Steven J Atlas
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Neil Korsen
- Center for Interdisciplinary Population and Health Research, Maine Medical Center, Portland, ME, USA
| | - Lauren Leavitt
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
| | - Vivian Lee
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
| | - Sanja Percac-Lima
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Brittney Mancini
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
| | - James Richter
- Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Elizabeth Scharnetzki
- Center for Interdisciplinary Population and Health Research, Maine Medical Center, Portland, ME, USA
| | - Lydia C Siegel
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - K D Valentine
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kathleen M Fairfield
- Center for Interdisciplinary Population and Health Research, Maine Medical Center, Portland, ME, USA
| | - Leigh H Simmons
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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5
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Dalton AF, Golin CE, Morris C, Kistler CE, Dolor RJ, Bertin KB, Suresh K, Patel SG, Lewis CL. Effect of a Patient Decision Aid on Preferences for Colorectal Cancer Screening Among Older Adults: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2244982. [PMID: 36469317 PMCID: PMC9855297 DOI: 10.1001/jamanetworkopen.2022.44982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Guidelines recommend individualized decision-making for colorectal cancer (CRC) screening among adults aged 76 to 84 years, a process that includes a consideration of health state and patient preference. OBJECTIVE To determine whether a targeted patient decision aid would align older adults' screening preference with their potential to benefit from CRC screening. DESIGN, SETTING, AND PARTICIPANTS This is a prespecified secondary analysis from a randomized clinical trial. Participants aged 70 to 84 years who were not up to date with screening and had an appointment within 6 weeks were purposively sampled by health state (poor, intermediate, or good) at 14 community-based primary care practices and block randomized to receive the intervention or control. Patients were recruited from March 1, 2012, to February 28, 2015, and these secondary analyses were performed from January 15 to March 1, 2022. INTERVENTIONS Patient decision aid targeted to age and sex. MAIN OUTCOMES AND MEASURES The primary outcome of this analysis was patient preference for CRC screening. The a priori hypothesis was that the decision aid (intervention) group would reduce the proportion preferring screening among those in poor and intermediate health compared with the control group. RESULTS Among the 424 participants, the mean (SD) age was 76.8 (4.2) years; 248 (58.5%) of participants were women; and 333 (78.5%) were White. The proportion preferring screening in the intervention group was less than in the control group for those in the intermediate health state (34 of 76 [44.7%] vs 40 of 73 [54.8%]; absolute difference, -10.1% [95% CI, -26.0% to 5.9%]) and in the poor health state (24 of 62 [38.7%] vs 33 of 61 [54.1%]; absolute difference, -15.4% [95% CI, -32.8% to 2.0%]). These differences were not statistically significant. The proportion of those in good health who preferred screening was similar between the intervention and control groups (44 of 74 [59.5%] for intervention vs 46 of 75 [61.3%] for control; absolute difference, -1.9% [95% CI, -17.6% to 13.8%]). CONCLUSIONS AND RELEVANCE The findings of this secondary analysis of a clinical trial did not demonstrate statistically significant differences in patient preferences between the health groups. Additional studies that are appropriately powered are needed to determine the effect of the decision aid on the preferences of older patients for CRC screening by health state. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01575990.
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Affiliation(s)
- Alexandra F. Dalton
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Carol E. Golin
- Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill
- Division of General Internal Medicine and Clinical Epidemiology, Department of Medicine, The University of North Carolina at Chapel Hill
- Gillings School of Global Public Health, Department of Health Behavior, The University of North Carolina at Chapel Hill
| | - Carolyn Morris
- Division of Data Sciences Safety and Regulatory, Division of Biostatistics, Department of Research & Development Solutions, IQVIA, Durham, North Carolina
| | - Christine E. Kistler
- Department of Family Medicine, School of Medicine, The University of North Carolina at Chapel Hill
| | - Rowena J. Dolor
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Kaitlyn B. Bertin
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora
| | - Krithika Suresh
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora
| | - Swati G. Patel
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
| | - Carmen L. Lewis
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
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Otsuki A, Saito J, Yaguchi‐Saito A, Odawara M, Fujimori M, Hayakawa M, Katanoda K, Matsuda T, Matsuoka YJ, Takahashi H, Takahashi M, Inoue M, Yoshimi I, Kreps GL, Uchitomi Y, Shimazu T. A nationally representative cross‐sectional survey on health information access for consumers in Japan: A protocol for the INFORM Study. WORLD MEDICAL & HEALTH POLICY 2022. [DOI: 10.1002/wmh3.506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Aki Otsuki
- Division of Behavioral Sciences, Behavioral Sciences and Survivorship Research Group, Center for Public Health Sciences National Cancer Center Tokyo Japan
| | - Junko Saito
- Division of Behavioral Sciences, Behavioral Sciences and Survivorship Research Group, Center for Public Health Sciences National Cancer Center Tokyo Japan
| | - Akiko Yaguchi‐Saito
- Division of Behavioral Sciences, Behavioral Sciences and Survivorship Research Group, Center for Public Health Sciences National Cancer Center Tokyo Japan
| | - Miyuki Odawara
- Division of Behavioral Sciences, Behavioral Sciences and Survivorship Research Group, Center for Public Health Sciences National Cancer Center Tokyo Japan
| | - Maiko Fujimori
- Division of Behavioral Sciences, Behavioral Sciences and Survivorship Research Group, Center for Public Health Sciences National Cancer Center Tokyo Japan
| | - Masayo Hayakawa
- Division of Cancer Information Service, Center for Cancer Control and Information Services National Cancer Center Tokyo Japan
| | - Kota Katanoda
- Division of Cancer Statistics Integration, Center for Cancer Control and Information Services National Cancer Center Tokyo Japan
| | - Tomohiro Matsuda
- Center for Cancer Registries, Center for Cancer Control and Information Services National Cancer Center Tokyo Japan
| | - Yutaka J. Matsuoka
- Division of Health Care Research, Behavioral Sciences and Survivorship Research Group, Center for Public Health Sciences National Cancer Center Tokyo Japan
| | - Hirokazu Takahashi
- Division of Cancer Screening Assessment and Management, Center for Public Health Sciences National Cancer Center Tokyo Japan
| | - Miyako Takahashi
- Division of Cancer Survivorship Research, Center for Cancer Control and Information Services National Cancer Center Tokyo Japan
- Japan Cancer Survivorship Network Tokyo Japan
- School of Medicine Iwate Medical University Iwate Japan
- Faculty of Medicine The Jikei University School of Medicine Tokyo Japan
| | - Manami Inoue
- Division of Prevention, Center for Public Health Sciences National Cancer Center Tokyo Japan
| | - Itsuro Yoshimi
- Division of Tabacco Policy Research, Center for Cancer Control and Information Services National Cancer Center Tokyo Japan
| | - Gary L. Kreps
- Department of Communication, Center for Health and Risk Communication George Mason University Fairfax Virginia USA
| | - Yosuke Uchitomi
- Division of Behavioral Sciences, Behavioral Sciences and Survivorship Research Group, Center for Public Health Sciences National Cancer Center Tokyo Japan
| | - Taichi Shimazu
- Division of Behavioral Sciences, Behavioral Sciences and Survivorship Research Group, Center for Public Health Sciences National Cancer Center Tokyo Japan
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7
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Smith J, Dodd RH, Gainey KM, Naganathan V, Cvejic E, Jansen J, McCaffery KJ. Patient-Reported Factors Associated With Older Adults' Cancer Screening Decision-making: A Systematic Review. JAMA Netw Open 2021; 4:e2133406. [PMID: 34748004 PMCID: PMC8576581 DOI: 10.1001/jamanetworkopen.2021.33406] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Decisions for older adults (aged ≥65 years) and their clinicians about whether to continue to screen for cancer are not easy. Many older adults who are frail or have limited life expectancy or comorbidities continue to be screened for cancer despite guidelines suggesting they should not; furthermore, many older adults have limited knowledge of the potential harms of continuing to be screened. OBJECTIVE To summarize the patient-reported factors associated with older adults' decisions regarding screening for breast, prostate, colorectal, and cervical cancer. EVIDENCE REVIEW Studies were identified by searching databases from January 2000 to June 2020 and were independently assessed for inclusion by 2 authors. Data extraction and risk of bias assessment were independently conducted by 2 authors, and then all decisions were cross-checked and discussed where necessary. Data analysis was performed from September to December 2020. FINDINGS The search yielded 2475 records, of which 21 unique studies were included. Nine studies were quantitative, 8 were qualitative, and 4 used mixed method designs. Of the 21 studies, 17 were conducted in the US, and 10 of 21 assessed breast cancer screening decisions only. Factors associated with decision-making were synthesized into 5 categories: demographic, health and clinical, psychological, physician, and social and system. Commonly identified factors associated with the decision to undergo screening included personal or family history of cancer, positive screening attitudes, routine or habit, to gain knowledge, friends, and a physician's recommendation. Factors associated with the decision to forgo screening included being older, negative screening attitudes, and desire not to know about cancer. Some factors had varying associations, including insurance coverage, living in a nursing home, prior screening experience, health problems, limited life expectancy, perceived cancer risk, risks of screening, family, and a physician's recommendation to stop. CONCLUSIONS AND RELEVANCE Although guidelines suggest incorporating life expectancy and health status to inform older adults' cancer screening decisions, older adults' ingrained beliefs about screening may run counter to these concepts. Communication strategies are needed that support older adults to make informed cancer screening decisions by addressing underlying screening beliefs in context with their perceived and actual risk of developing cancer.
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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
| | - Karen M. Gainey
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing, Concord Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Erin Cvejic
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jesse Jansen
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Kirsten J. McCaffery
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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8
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Bjørk E, Thompson W, Ryg J, Gaardboe O, Jørgensen TL, Lundby C. Patient Preferences for Discussing Life Expectancy: a Systematic Review. J Gen Intern Med 2021; 36:3136-3147. [PMID: 34338978 PMCID: PMC8481511 DOI: 10.1007/s11606-021-06973-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 06/07/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Discussing life expectancy helps inform decisions related to preventive medication, screening, and personal care planning. Our aim was to systematically review the literature on patient preferences for discussing life expectancy and to identify predictors for these preferences. METHODS We searched PubMed, Cochrane Library, Embase, MEDLINE, PsycInfo, and gray literature from inception until 17 February 2021. Two authors screened titles/abstracts and full texts, and extracted data and one author assessed quality. The outcome of interest was the proportion of patients willing to discuss life expectancy. We reported descriptive statistics, performed a narrative synthesis, and explored sub-groups of patients according to patient characteristics. RESULTS A total of 41 studies with an accumulated population of 27,570 participants were included, comprising quantitative survey/questionnaire studies (n=27) and qualitative interview studies (n=14). Willingness to discuss life expectancy ranged from 19 to 100% (median 61%, interquartile range (IQR) 50-73) across studies, with the majority (77%) reporting more than half of subjects willing to discuss. There was considerable heterogeneity in willingness to discuss life expectancy, even between studies from patients with similar ages, diseases, and cultural profiles. The highest variability in willingness to discuss was found among patients with cancer (range 19-100%, median 61%, IQR 51-81) and patients aged 50-64 years (range 19-97%, median 61%, IQR 45-87). This made it impossible to determine predictors for willingness to discuss life expectancy. DISCUSSION Most patients are willing to discuss life expectancy; however, a substantial proportion is not. Heterogeneity and variability in preferences make it challenging to identify clear predictors of willingness to discuss. Variability in preferences may to some extent be influenced by age, disease, and cultural differences. These findings highlight the individual and complex nature in which patients approach this topic and stress the importance of clinicians considering eliciting patient's individual preferences when initiating discussions about life expectancy.
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Affiliation(s)
- Emma Bjørk
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense C, Denmark.
| | - Wade Thompson
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense C, Denmark
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark
- Odense Deprescribing Initiative (ODIN), Odense C, Denmark
| | - Jesper Ryg
- Odense Deprescribing Initiative (ODIN), Odense C, Denmark
- Department of Geriatric Medicine, Odense University Hospital, Odense C, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
- Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Odense C, Denmark
| | - Ove Gaardboe
- Danish Society for Patient Safety, Frederiksberg, Denmark
| | - Trine Lembrecht Jørgensen
- Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Odense C, Denmark
- Department of Oncology, Odense University Hospital, Odense C, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Carina Lundby
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense C, Denmark
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense C, Denmark
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark
- Odense Deprescribing Initiative (ODIN), Odense C, Denmark
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9
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Schoenborn NL, Boyd CM, Pollack CE. Impact of the COVID-19 pandemic on cancer screening attitudes, intentions, and behaviors in older adults. J Am Geriatr Soc 2021; 70:67-69. [PMID: 34449873 PMCID: PMC8657344 DOI: 10.1111/jgs.17449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 07/30/2021] [Accepted: 08/15/2021] [Indexed: 12/25/2022]
Affiliation(s)
- Nancy L Schoenborn
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Cynthia M Boyd
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Craig E Pollack
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,The Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
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10
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Piper MS, Zikmund-Fisher BJ, Maratt JK, Kurlander J, Metko V, Waljee AK, Saini SD. Patients' Willingness to Share Limited Endoscopic Resources: A Brief Report on the Results of a Large Regional Survey. MDM Policy Pract 2021; 6:23814683211045648. [PMID: 34616912 PMCID: PMC8488065 DOI: 10.1177/23814683211045648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 08/05/2021] [Indexed: 12/25/2022] Open
Abstract
Background. In some health care systems, patients face long wait times for screening colonoscopy. We sought to assess whether patients at low risk for colorectal cancer (CRC) would be willing to delay their own colonoscopy so higher-risk peers could undergo colonoscopy sooner. Methods. We surveyed 1054 Veterans regarding their attitudes toward repeat colonoscopy and risk-based prioritization. We used multivariable regression to identify patient factors associated with willingness to delay screening for a higher-risk peer. Results. Despite a physician recommendation to stop screening, 29% of respondents reported being "not at all likely" to stop. However, 94% reported that they would be willing to delay their own colonoscopy for a higher-risk peer. Greater trust in physician and greater health literacy were positively associated with willingness to wait, while greater perceived threat of CRC and Black or Latino race/ethnicity were negatively associated with willingness to wait. Conclusion. Despite high enthusiasm for repeat screening, patients were willing to delay their own colonoscopy for higher-risk peers. Appealing to altruism could be effective when utilizing scarce resources.
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Affiliation(s)
- Marc S. Piper
- Division of Gastroenterology, Department of
Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Division of Gastroenterology, Department of
Internal Medicine, Providence Park Hospital, Michigan State University
College of Human Medicine, Southfield, Michigan
| | - Brian J. Zikmund-Fisher
- Department of Health Behavior and Health
Education, University of Michigan School of Public Health, Ann Arbor,
Michigan
- Department of Internal Medicine, University of
Michigan Medical School, Ann Arbor, Michigan
| | - Jennifer K. Maratt
- Division of Gastroenterology, Department of
Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Division of Gastroenterology, Department of
Internal Medicine, Indiana University School of Medicine, Indianapolis,
Indiana
- Richard L. Roudebush VA Medical Center,
Indianapolis, Indiana
- Regenstrief Institute, Inc, Indianapolis,
Indiana
| | - Jacob Kurlander
- Division of Gastroenterology, Department of
Internal Medicine, University of Michigan, Ann Arbor, Michigan
- VA HSR&D Center for Clinical Management
Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Valbona Metko
- Division of Gastroenterology, Department of
Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Akbar K. Waljee
- Division of Gastroenterology, Department of
Internal Medicine, University of Michigan, Ann Arbor, Michigan
- VA HSR&D Center for Clinical Management
Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Sameer D. Saini
- Division of Gastroenterology, Department of
Internal Medicine, University of Michigan, Ann Arbor, Michigan
- VA HSR&D Center for Clinical Management
Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
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11
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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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12
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Roy S, Moss JL, Rodriguez-Colon SM, Shen C, Cooper JD, Lennon RP, Lengerich EJ, Adelman A, Curry W, Ruffin MT. Examining Older Adults' Attitudes and Perceptions of Cancer Screening and Overscreening: A Qualitative Study. J Prim Care Community Health 2020; 11:2150132720959234. [PMID: 33054558 PMCID: PMC7576932 DOI: 10.1177/2150132720959234] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Introduction/Objectives: Screening guidelines for breast, cervical, and colorectal cancer (CRC) are less clear for older adults due to the potential harms that may result from screening. Understanding older adults’ attitudes and perceptions, especially racial/ethnic minority and underserved adults, of cancer screening can help health care providers determine how best to communicate with older adults about cancer screening and screening cessation. The objective of this study was to determine how older adults primarily from minority/underserved backgrounds perceive cancer screening and overscreening. Methods: Four focus groups (n = 39) were conducted with adults (>=65 years of age) in 3 community settings in south-central Pennsylvania. Two focus groups were conducted in Spanish and translated to English upon transcription. Focus group data was managed and analyzed using QSR NVivo 12. Inductive thematic analysis was used to analyze the data where themes emerged following the coding process. Results: The focus group participants had an average age of 74 years and were primarily female (74%) and Hispanic (69%), with 69% reporting having less than a high school degree. Four key themes were identified from the focus groups: (1) importance of tailored and targeted education/information; (2) impact of physician/patient communication; (3) impact of barriers and facilitators to screening on cancer screening cessation; and (4) awareness of importance of screening. Participants were more likely to be agreeable to screening cessation if they received specific information regarding their health status and previous medical history from their physician as to why screening should be stopped and told by their physician that the screening decision is up to them. Conclusions: Older adults prefer individualized information from their physician in order to justify screening cessation but are against incorporating life expectancy into the discussion. Future research should focus on developing interventions to test the effectiveness of culturally tailored screening cessation messages for older adults.
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Affiliation(s)
| | | | | | - Chan Shen
- Penn State College of Medicine, Hershey, PA, USA
| | | | | | | | - Alan Adelman
- Penn State College of Medicine, Hershey, PA, USA
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13
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Luu XQ, Lee K, Lee YY, Suh M, Kim Y, Choi KS. Acceptance on colorectal cancer screening upper age limit in South Korea. World J Gastroenterol 2020; 26:3963-3974. [PMID: 32774070 PMCID: PMC7385558 DOI: 10.3748/wjg.v26.i27.3963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/06/2020] [Accepted: 07/04/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The Korea National Cancer Screening Program currently provides screening for colorectal cancer (CRC) for adults older than 50 years with no upper age limit. In general, people are likely to only pay attention to the benefits of cancer screening and to neglect its risks. Most consider the benefits of cancer screening as being far greater than the risks and are unaware that any potential benefits and harms can vary with age.
AIM To report acceptance of an upper age limit for CRC screening and factors associated therewith among cancer-free individuals in Korea.
METHODS The present study analyzed data from the Korea National Cancer Screening Survey 2017, a nationally representative random sample of 4500 Korean individuals targeted for screening for the five most common types of cancer. A total of 1922 participants were included in the final analysis. The baseline characteristics of the study population are presented as unweighted numbers and weighted proportions. Both univariate and multivariate logistic regression models were developed to examine factors related with acceptance of an upper age limit for CRC screening; subgroup analysis was also applied.
RESULTS About 80% (1554/1922) of the respondents agreed that CRC screening should not be offered for individuals older than 80 years. Specifically, those who had never been screened for CRC had the highest acceptance rate (91%). Overall, screening history for CRC [screened by both fecal occult blood test and colonoscopy, adjusted odds ratio (aOR) = 0.33, 95%CI: 0.22-0.50] and other cancers (aOR = 0.55, 95%CI: 0.34-0.87), as well as a family history of cancer (aOR = 0.66, 95%CI: 0.50-0.87), were negatively associated with acceptance of an upper age limit for CRC screening. In contrast, metropolitan residents (aOR = 1.86, 95%CI: 1.29-2.68) and people who exercised regularly (aOR = 1.42, 95%CI: 1.07-1.89) were more likely to accept an upper age limit. After subgrouping, we found gender, marital status, and lifetime smoking history among never-screened individuals and residential region, family history of cancer, and physical activity among never-screened individuals to be associated with acceptance of an upper age limit.
CONCLUSION This study describes acceptance of an upper age limit for CRC screening and factors associated with it, and provides perspectives that should be considered, in addition to scientific evidence, when developing population-based cancer screening policies and programs.
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Affiliation(s)
- Xuan Quy Luu
- Graduate School of Cancer Science and Policy, National Cancer Center, Goyang-si 10408, South Korea
| | - Kyeongmin Lee
- Graduate School of Cancer Science and Policy, National Cancer Center, Goyang-si 10408, South Korea
| | - Yun Yeong Lee
- National Cancer Control Institute, National Cancer Center, Goyang-si 10408, South Korea
| | - Mina Suh
- National Cancer Control Institute, National Cancer Center, Goyang-si 10408, South Korea
| | - Yeol Kim
- National Cancer Control Institute, National Cancer Center, Goyang-si 10408, South Korea
| | - Kui Son Choi
- Graduate School of Cancer Science and Policy, National Cancer Center, Goyang-si 10408, South Korea
- National Cancer Control Institute, National Cancer Center, Goyang-si 10408, South Korea
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14
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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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15
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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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16
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Moss JL, Roy S, Shen C, Cooper JD, Lennon RP, Lengerich EJ, Adelman A, Curry W, Ruffin MT. Geographic Variation in Overscreening for Colorectal, Cervical, and Breast Cancer Among Older Adults. JAMA Netw Open 2020; 3:e2011645. [PMID: 32716514 PMCID: PMC8127072 DOI: 10.1001/jamanetworkopen.2020.11645] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE National guidelines balance risks and benefits of population-level cancer screening among adults with average risk. Older adults are not recommended to receive routine screening, but many continue to be screened (ie, are overscreened). OBJECTIVE To assess the prevalence of overscreening for colorectal, cervical, and breast cancers among older adults as well as differences in overscreening by metropolitan status. DESIGN, SETTING, AND PARTICIPANTS The cross-sectional study examined responses to a telephone survey of 176 348 community-dwelling adults. Participants were included if they met age and sex criteria, and they were excluded from each cancer-specific subsample if they had a history of that cancer. Data came from the 2018 Behavioral Risk Factor Surveillance System, administered by the US Centers for Disease Control and Prevention. EXPOSURES Metropolitan status, according to whether participants lived in a metropolitan statistical area. MAIN OUTCOMES AND MEASURES Overscreening was assessed using US Preventive Services Task Force definitions, ie, whether participants self-reported having a screening after the recommended upper age limit for colorectal (75 years), cervical (65 years), or breast (74 years) cancer. RESULTS Of 176 348 participants (155 411 [88.1%] women; mean [SE] age, 75.0 [0.04] years; 150 871 [85.6%] non-Hispanic white; 60 456 [34.3%] with nonmetropolitan residence) the cancer-specific subsamples contained 20 937 [11.9%] men and 34 244 [19.4%] women for colorectal cancer, 82 811 [47.0%] women for cervical cancer, and 38 356 [21.8%] women for breast cancer. Overall, 9461 men (59.3%; 95% CI, 57.6%-61.1%) were overscreened for colorectal cancer; 14 463 women (56.2%; 95% CI, 54.7%-57.6%), for colorectal cancer; 31 988 women (45.8%; 95% CI, 44.9%-46.7%), for cervical cancer; and 26 198 women (74.1%; 95% CI, 73.0%-75.3%), for breast cancer. Overscreening was more common in metropolitan than nonmetropolitan areas for colorectal cancer among women (adjusted odds ratio [aOR], 1.23; 95% CI, 1.08-1.39), cervical cancer (aOR, 1.20; 95% CI, 1.11-1.29), and breast cancer (aOR, 1.36; 95% CI, 1.17-1.57). Overscreening for cervical and breast cancers was also associated with having a usual source of care compared with not (eg, cervical cancer: aOR, 1.87; 95% CI, 1.56-2.25; breast cancer: aOR, 2.08; 95% CI, 1.58-2.76), good, very good, or excellent self-reported health compared with fair or poor self-reported health (eg, cervical cancer: aOR, 1.21; 95% CI, 1.11-1.32; breast cancer: aOR, 1.47; 95% CI, 1.28-1.69), an educational attainment greater than a high school diploma compared with a high school diploma or less (eg, cervical cancer: aOR, 1.14; 95% CI, 1.06-1.23; breast cancer: aOR, 1.30; 95% CI, 1.16-1.46), and being married or living as married compared with other marital status (eg, cervical cancer: OR, 1.36; 95% CI, 1.26-1.46; breast cancer: OR, 1.54; 95% CI, 1.34-1.77). CONCLUSIONS AND RELEVANCE In this study, overscreening for cancer among older adults was high, particularly for women living in metropolitan areas. Overscreening could be associated with health care access and patient-clinician relationships. Additional research on why overscreening persists and how to reduce overscreening is needed to minimize risks associated with cancer screening among older adults.
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Affiliation(s)
| | | | - Chan Shen
- Penn State College of Medicine, Hershey, Pennsylvania
| | - Joie D Cooper
- Penn State College of Medicine, Hershey, Pennsylvania
| | | | | | - Alan Adelman
- Penn State College of Medicine, Hershey, Pennsylvania
| | - William Curry
- Penn State College of Medicine, Hershey, Pennsylvania
| | - Mack T Ruffin
- Penn State College of Medicine, Hershey, Pennsylvania
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17
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Schoenborn NL, Crossnohere NL, Janssen EM, Pollack CE, Boyd CM, Wolff AC, Xue QL, Massare J, Blinka M, Bridges JFP. Examining Generalizability of Older Adults' Preferences for Discussing Cessation of Screening Colonoscopies in Older Adults with Low Health Literacy. J Gen Intern Med 2019; 34:2512-2519. [PMID: 31452029 PMCID: PMC6848333 DOI: 10.1007/s11606-019-05258-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 04/23/2019] [Accepted: 07/09/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND/OBJECTIVES Many older adults receive unnecessary screening colonoscopies. We previously conducted a survey using a national online panel to assess older adults' preferences for how clinicians can discuss stopping screening colonoscopies. We sought to assess the generalizability of those results by comparing them to a sample of older adults with low health literacy. DESIGN Cross-sectional survey. SETTING Baltimore metropolitan area (low health literacy sample) and a national, probability-based online panel-KnowledgePanel (national sample). PARTICIPANTS Adults 65+ with low health literacy measured using a single-question screen (low health literacy sample, n = 113) and KnowledgePanel members 65+ who completed survey about colorectal cancer screening (national sample, n = 441). MEASUREMENTS The same survey was administered to both groups. Using the best-worst scaling method, we assessed relative preferences for 13 different ways to explain stopping screening colonoscopies. We used conditional logistic regression to quantify the relative preference for each explanation, where a higher preference weight indicates stronger preference. We analyzed each sample separately, then compared the two samples using Spearman's correlation coefficient, the likelihood ratio test to assess for overall differences between the two sets of preference weights, and the Wald test to assess differences in preference weights for each individual phrases. RESULTS The responses from the two samples were highly correlated (Spearman's coefficient 0.92, p < 0.0001). The most preferred phrase to explain stopping screening colonoscopy was "Your other health issues should take priority" in both groups. The three least preferred options were also the same for both groups, with the least preferred being "The doctor does not give an explanation." The explanation that referred to "quality of life" was more preferred by the low health literacy group whereas explanations that mentioned "unlikely to benefit" and "high risk for harms" were more preferred by the national survey group (all p < 0.001). CONCLUSION Among two different populations of older adults with different health literacy levels, the preferred strategies for clinicians to discuss stopping screening colonoscopies were highly correlated. Our results can inform effective communication about stopping screening colonoscopies in older adults across different health literacy levels.
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Affiliation(s)
| | - Norah L Crossnohere
- The Johns Hopkins University School of Public Health, Baltimore, MD, USA.,Department of Biomedical Informatics, Ohio State University, Columbus, OH, USA
| | | | - Craig E Pollack
- The Johns Hopkins University School of Public Health, Baltimore, MD, USA
| | - Cynthia M Boyd
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Antonio C Wolff
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Qian-Li Xue
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Johns Hopkins University School of Public Health, Baltimore, MD, USA
| | | | - Marcela Blinka
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John F P Bridges
- Department of Biomedical Informatics, Ohio State University, Columbus, OH, USA
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18
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Abstract
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.
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Affiliation(s)
- Scott J Pilla
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Welch Center for Prevention, Epidemiology & Clinical Research, Baltimore, MD, USA.
| | - Nancy L Schoenborn
- Department of Medicine, Division of Geriatric Medicine and Gerontology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nisa M Maruthur
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology & Clinical Research, Baltimore, MD, USA
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elbert S Huang
- Division of General Internal Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA
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19
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Preferences for Surveillance of Barrett's Oesophagus: a Discrete Choice Experiment. J Gastrointest Surg 2019; 23:1309-1317. [PMID: 30478530 DOI: 10.1007/s11605-018-4049-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 11/05/2018] [Indexed: 01/31/2023]
Abstract
PURPOSE Endoscopic surveillance for Barrett's oesophagus is undertaken to detect dysplasia and early cancer, and to facilitate early intervention. Evidence supporting current practice is of low quality and often influenced by opinion. This study investigated the preferences of patients for surveillance of Barrett's oesophagus in an Australian cohort. METHODS Four Barrett's oesophagus surveillance characteristics/attributes were evaluated within a discrete choice experiment based on literature and expert opinion: (1) surveillance method (endoscopy vs a blood test vs a novel breath test), (2) risk of missing a cancer over a 10-year period, (3) screening interval, and (4) out-of-pocket cost. The data from the discrete choice experiment was analysed within the framework of random utility theory using a mixed logit regression model. RESULTS The study sample comprised patients (n = 71) undergoing endoscopic surveillance for Barrett's oesophagus of whom n = 65 completed the discrete choice experiment. The sample was predominantly male (77%) with average age of 65 years. All attributes except surveillance method significantly influenced respondents' preference for Barrett's oesophagus surveillance. Policy analyses suggested that compared to the reference case (i.e. endoscopy provided annually at no upfront cost and with a 4% risk of missing cancer), increasing test sensitivity to 0.5% risk of missing cancer would increase participation by up to 50%; surveillance every 5 years would lead to 26% reduction, while every 3 to 3.5 years would result in 7% increase in participation. Respondents were highly averse to paying A$500 for the test, resulting in 48% reduction in participation. None of the other surveillance methods was preferred to endoscopy, both resulting in 11% reduction in participation. CONCLUSION Test sensitivity, test frequency and out-of-pocket cost were the key factors influencing surveillance uptake. Patients prefer a test with the highest sensitivity, offered frequently, that incurs no upfront costs.
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20
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Janssen EM, Pollack CE, Boyd C, Bridges JFP, Xue QL, Wolff AC, Schoenborn NL. How Do Older Adults Consider Age, Life Expectancy, Quality of Life, and Physician Recommendations When Making Cancer Screening Decisions? Results from a National Survey Using a Discrete Choice Experiment. Med Decis Making 2019; 39:621-631. [PMID: 31226903 DOI: 10.1177/0272989x19853516] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background. Older adults with limited life expectancy frequently receive cancer screening, although on average, harms outweigh benefits. We examined the influence of life expectancy on older adults' cancer screening decisions relative to three other factors. Methods. Adults aged 65+ years (N = 1272) were recruited from a national online survey panel. Using a discrete choice experiment, we systematically varied a hypothetical patient's life expectancy, age, quality of life, and physician's recommendation and asked whether the participant would choose screening. Participants were randomized to questions about colonoscopy or prostate-specific antigen/mammography screenings. Logistic regression produced preference weights that quantified the relative influence of the 4 factors on screening decisions. Results. 879 older adults completed the survey, 660 of whom varied their screening choices in response to the 4 factors we tested. The age of the hypothetical patient had the largest influence on choosing screening: the effect of age being 65 versus 85 years had a preference weight of 2.44 (95% confidence interval [CI]: 2.22, 2.65). Life expectancy (10 versus 1 year) had the second largest influence (preference weight: 1.64, CI: 1.41, 1.87). Physician recommendation (screen versus do not screen) and quality of life (good versus poor) were less influential, with preference weights of 0.90 (CI: 0.72, 1.08) and 0.68 (CI: 0.52, 0.83), respectively. Conclusions. While clinical practice guidelines increasingly use life expectancy in addition to age to guide screening decisions, we find that age is the most influential factor, independent of life expectancy, quality of life, and physician recommendation, in older adults' cancer screening choices. Strategies to reduce overscreening should consider the importance patients give to continuing screening at younger ages, even when life expectancy is limited.
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Affiliation(s)
- Ellen M Janssen
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD, USA.,Center for Medical Technology Policy, Baltimore, MD, USA
| | - Craig E Pollack
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cynthia Boyd
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Qian-Li Xue
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Antonio C Wolff
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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21
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Warner DF, Koroukian SM, Schiltz NK, Smyth KA, Cooper GS, Owusu C, Stange KC, Berger NA. Complex Multimorbidity and Breast Cancer Screening Among Midlife and Older Women: The Role of Perceived Need. THE GERONTOLOGIST 2019; 59:S77-S87. [PMID: 31100139 PMCID: PMC6524759 DOI: 10.1093/geront/gny180] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There is minimal survival benefit to cancer screening for those with poor clinical presentation (complex multimorbidity) or at advanced ages. The current screening mammography guidelines consider these objective indicators. There has been less attention, however, to women's subjective assessment of screening need. This study examines the interplay between complex multimorbidity, age, and subjective assessments of health and longevity for screening mammography receipt. RESEARCH DESIGN AND METHOD This cross-sectional study uses self-reported data from 8,938 women over the age of 52 in the 2012 Health and Retirement Study. Logistic regression models estimated the association between women's complex multimorbidity (co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes), subjective health and longevity assessments, age, and screening mammography in the 2 years before the interview. These associations were evaluated adjusting for sociodemographic and behavioral factors. RESULTS Both age and complex multimorbidity were negatively associated with screening mammography. However, women's perceived need for screening moderated these effects. Most significantly, women optimistic about their chances of living another 10-15 years were more likely to have had screening mammography regardless of their health conditions or advanced age. DISCUSSION AND IMPLICATIONS Women with more favorable self-assessed health and perceived life expectancy were more likely to receive screening mammography even if they have poor clinical presentation or advanced age. This is contrary to current cancer screening guidelines and suggests an opportunity to engage women's subjective health and longevity assessments for cancer screening decision making in both for screening policy and in individual clinician recommendations.
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Affiliation(s)
- David F Warner
- Department of Sociology, University of Nebraska–Lincoln
- Center for Family & Demographic Research, Bowling Green State University, Ohio
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences
- Case Comprehensive Cancer Center, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | | | | | - Gregory S Cooper
- Case Comprehensive Cancer Center, School of Medicine, Case Western Reserve University, Cleveland, Ohio
- Division of Gastroenterology, Case Western Reserve University, Cleveland, Ohio
| | - Cynthia Owusu
- Case Comprehensive Cancer Center, School of Medicine, Case Western Reserve University, Cleveland, Ohio
- Division of Hematology/Oncology, Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Kurt C Stange
- Case Comprehensive Cancer Center, School of Medicine, Case Western Reserve University, Cleveland, Ohio
- Department of Family Medicine and Community Health, Case Western Reserve University, Cleveland, Ohio
- Center for Community Health Integration, School of Medicine, Case Western Reserve University, Cleveland, Ohio
- Department of Sociology, Case Western Reserve University, Cleveland, Ohio
| | - Nathan A Berger
- Case Comprehensive Cancer Center, School of Medicine, Case Western Reserve University, Cleveland, Ohio
- Division of Hematology/Oncology, Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, Ohio
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22
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Schoenborn NL, Boyd CM, Lee SJ, Cayea D, Pollack CE. Communicating About Stopping Cancer Screening: Comparing Clinicians' and Older Adults' Perspectives. THE GERONTOLOGIST 2019; 59:S67-S76. [PMID: 31100135 PMCID: PMC6524758 DOI: 10.1093/geront/gny172] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Older adults with limited life expectancy frequently receive cancer screening. We sought to compare the perspectives of clinicians and older adults on how to communicate about stopping cancer screening. RESEARCH DESIGN AND METHODS We used data from two studies involving semistructured in-person individual interviews, in which we asked about perspectives on communication about stopping cancer screening, with 28 primary care clinicians and 40 community-dwelling older adults, respectively. RESULTS We identified three major themes: (a) Consensus among primary care clinicians and older adults regarding communication around stopping cancer screening. Both groups considered discussing the benefits/risks of cancer screening and involving patients in the decision as important and mentioned framing screening cessation as shift in health priorities. (b) Differences in perceived reactions to stopping cancer screening. Primary care clinicians were concerned about patient reaction to stopping cancer screening, whereas older adults reported no negative reactions in the context of a trusting relationship. (c) Differences in views around whether to discuss life expectancy in the context of stopping cancer screening. Clinicians rarely discussed life expectancy in this context, whereas older adults were divided on whether life expectancy should be discussed. DISCUSSION AND IMPLICATIONS Given the heterogeneity in older adults' preferences, it is important to assess whether patients want to discuss life expectancy when discussing stopping cancer screening, though use of the specific term "life expectancy" may not be necessary. Instead, focusing discussion on the benefits/risks of cancer screening and mentioning shift in health priorities are acceptable communication strategies for both clinicians and older adults.
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Affiliation(s)
- Nancy L Schoenborn
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cynthia M Boyd
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sei J Lee
- Department of Medicine, University of California, San Francisco
| | - Danelle Cayea
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Craig E Pollack
- Department of Health Policy and Management, Johns Hopkins University School of Public Health, Baltimore, Maryland
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23
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Schoenborn NL, Xue QL, Pollack CE, Janssen EM, Bridges JF, Wolff AC, Boyd CM. Demographic, health, and attitudinal factors predictive of cancer screening decisions in older adults. Prev Med Rep 2019; 13:244-248. [PMID: 30719405 PMCID: PMC6350222 DOI: 10.1016/j.pmedr.2019.01.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 01/09/2019] [Accepted: 01/15/2019] [Indexed: 11/19/2022] Open
Abstract
Many older adults receive routine cancer screening even when it is no longer recommended. We sought to identify demographic, health-related, and attitudinal factors that are most predictive of continued breast, colorectal, and prostate cancer screening decisions in older adults under various scenarios. A sample of adults age 65+ (n = 1272) were recruited from a nationally representative panel in November 2016, of which 881 (69.3%) completed our survey. Participants were presented vignettes in which we experimentally varied a hypothetical patient's life expectancy, age, quality of life, and physician screening recommendation. The dependent variable was the choice to continue cancer screening in the vignette. Classification and regression tree (CART) analysis was used to identify characteristics most predictive of screening decisions; both the participants' characteristics and the hypothetical patient's characteristics in the vignettes were included in the analysis. CART analysis uses recursive partitioning to create a classification tree in which variables predictive of the outcome are included as hierarchical tree nodes. We used automated ten-fold cross-validation to select the tree with lowest misclassification and highest predictive accuracy. Participants' attitude towards cancer screening was most predictive of choosing screening. Among those who agreed with the statement "I plan to get screened for cancer for as long as I live" (n = 300, 31.9%), 73.2% chose screening and 57.2% would still choose screening if hypothetical patient had 1-year life expectancy. For this subset of older adults with enthusiasm towards screening even when presented with scenario involving limited life expectancy, efforts are needed to improve informed decision-making about screening.
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Affiliation(s)
- Nancy L. Schoenborn
- The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Qian-Li Xue
- The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
- The Johns Hopkins University School of Public Health, Baltimore, MD, United States of America
| | - Craig E. Pollack
- The Johns Hopkins University School of Public Health, Baltimore, MD, United States of America
| | | | - John F.P. Bridges
- Ohio State University, Department of Biomedical Informatics, Columbus, OH, United States of America
| | - Antonio C. Wolff
- The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Cynthia M. Boyd
- The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
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24
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Piper MS, Maratt JK, Zikmund-Fisher BJ, Lewis C, Forman J, Vijan S, Metko V, Saini SD. Patient Attitudes Toward Individualized Recommendations to Stop Low-Value Colorectal Cancer Screening. JAMA Netw Open 2018; 1:e185461. [PMID: 30646275 PMCID: PMC6324357 DOI: 10.1001/jamanetworkopen.2018.5461] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Guidelines for colorectal cancer (CRC) screening recommend an individualized approach in older adults that is informed by consideration of life expectancy and cancer risk. However, little is known about how patients perceive individualized screening recommendations. OBJECTIVE To assess veterans' attitudes toward and comfort with cessation of low-value CRC screening (defined as screening in a patient for whom the benefit is expected to be small based on quantitative estimates from hypothetical risk calculators). DESIGN, SETTING, AND PARTICIPANTS This survey study included patients older than 50 years who had undergone prior screening colonoscopy with normal results at the Veterans Affairs Ann Arbor Healthcare System. A total of 1500 surveys were mailed to potential participants from November 1, 2010, to January 1, 2012. Survey data were analyzed from January 1, 2016, to December 31, 2017. MAIN OUTCOMES AND MEASURES Response to the question, "If you personally had serious health problems that were likely to shorten your life and your doctor did not think screening would be of much benefit based on the calculator, how comfortable would you be with not getting any more screening colonoscopies?" RESULTS Of the 1500 surveys mailed, 85 were returned to sender, leaving 1415 potential respondents; 1054 of these respondents (median age range, 60-69 years; 884 [85.9%] white and 965 [94.2%] male) completed the survey (response rate, 74.5%). A total of 300 (28.7%) were not at all comfortable with cessation of low-value CRC screening, and 509 (49.3%) thought that age should never be used to decide when to stop screening. In addition, 332 (31.7%) thought it was not at all reasonable to use life expectancy calculators, and 255 (24.3%) thought it was not at all reasonable to use CRC risk calculators to guide these decisions. In ordered logistic regression analysis, factors associated with more comfort with screening cessation were (1) higher trust in physician (odds ratio [OR], 1.19; 95% CI, 1.07-1.32), (2) higher perceived health status (OR, 1.41; 95% CI, 1.23-1.61), and (3) higher barriers to screening (OR, 1.20; 95% CI, 1.11-1.30). Factors that were associated with less comfort with screening cessation included (1) greater perceived effectiveness of screening (OR, 0.86; 95% CI, 0.80-0.94) and (2) greater perceived threat of CRC (OR, 0.81; 95% CI, 0.73-0.89). CONCLUSIONS AND RELEVANCE The findings suggest that many veterans have strong preferences against screening cessation even when given detailed information about why the benefit may be low. Efforts to tailor screening recommendations may be met by resistance unless they are accompanied by efforts to address underlying perceptions about the benefit of screening.
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Affiliation(s)
- Marc S. Piper
- Division of Gastroenterology, Department of Internal Medicine, Providence-Providence Park Hospital, Michigan State University College of Human Medicine, Southfield
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Jennifer K. Maratt
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Brian J. Zikmund-Fisher
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Carmen Lewis
- Division of General Internal Medicine, Department of Internal Medicine, University of Colorado, Aurora
| | - Jane Forman
- Veterans Affairs (VA) Health Services Research and Development Service Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Sandeep Vijan
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
- Veterans Affairs (VA) Health Services Research and Development Service Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Valbona Metko
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Sameer D. Saini
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor
- Veterans Affairs (VA) Health Services Research and Development Service Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
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25
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Kistler CE, Golin C, Sundaram A, Morris C, Dalton AF, Ferrari R, Lewis CL. Individualized Colorectal Cancer Screening Discussions Between Older Adults and Their Primary Care Providers: A Cross-Sectional Study. MDM Policy Pract 2018; 3:2381468318765172. [PMID: 30288441 PMCID: PMC6157429 DOI: 10.1177/2381468318765172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 02/08/2018] [Indexed: 01/08/2023] Open
Abstract
Introduction. Discussions of colorectal cancer (CRC) screening with older adults should be individualized to maximize appropriate screening. Our aim was to describe CRC screening discussions and explore their associations with patient characteristics and screening intentions. Methods. Cross-sectional survey of 422 primary care patients aged ≥70 years and eligible for CRC screening, including open-ended questions about CRC screening discussions. Primary outcomes were the frequency with which CRC screening discussions occurred, who had those discussions, and the domains that emerged from thematic analysis of participants' brief reports of their discussions. We also examined the associations between 1) patient characteristics and whether a screening discussion occurred and 2) the domains discussed and what screening decisions were made. Results. Of 422 participants, 209 reported having discussions and 201 responded to open-ended questions about CRC discussions. In a regression analysis, several factors were associated with increased odds of having a discussion: participants' preference to pursue screening (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.3, 3.9), good health (OR 2.9, 95% CI 1.7, 4.8), and receipt of the decision aid (OR 2.1, 95% CI 1.4, 3.2). Our thematic analysis identified five domains related to discussion content and three related to discussion process. The CRC screening-related information domain was the most commonly discussed content domain, and the timing/frequency domain was associated with increased odds of intent to pursue screening. Decision-making role, the most commonly discussed process domain, was associated with increased odds of the intent to forgo CRC screening. Conclusions and Relevance. CRC screening discussions varied by type of participant and content. Future work is needed to determine if interventions focused on specific domains alters the appropriateness of participants' colorectal cancer screening intentions.
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Affiliation(s)
- Christine E Kistler
- Department of Family Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Carol Golin
- Department of Medicine, and Department of Health Behavior, Gillings School of Global Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anupama Sundaram
- School of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Carolyn Morris
- Department of Family Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Alexandra F Dalton
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Renee Ferrari
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carmen L Lewis
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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26
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Law M, Dhillon S, Herrmann N, Friesen F, Dey AK, Li A, Ayala AP, Lenton E, Edwards JD, Swardfager W. Rates of Screening for Breast, Colorectal, and Cervical Cancers in Older People With Cognitive Impairment or Dementia: A Meta-Analysis. Gerontol Geriatr Med 2018; 4:2333721418799446. [PMID: 30246059 PMCID: PMC6144494 DOI: 10.1177/2333721418799446] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/03/2018] [Accepted: 08/14/2018] [Indexed: 12/18/2022] Open
Abstract
Purpose: Cancer screening may not be appropriate for some older
people. We compare the likelihood of screening for colorectal, breast, and
cervical cancers in older people with versus without cognitive impairment or
dementia. Method: Systematic search of MEDLINE, Embase, and
PsycINFO (to March 9, 2018) for articles reporting screening for colon, breast,
and cervical cancers in patients with and without cognitive impairment or
dementia. Studies were summarized quantitatively (random effects meta-analysis),
according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) guidelines. Results: Studies reported data 1989-2008. The
rate of screening for breast cancer by mammography was lower in women with
cognitive impairment or dementia compared with those without (pooled odds ratio
[OR] = 0.81, 95% confidence interval [CI] = [0.71, 0.91], p =
.0007, six studies, N = 18,562). The rates of screening for
cervical cancer by Pap smear (pooled OR = 0.88, 95% CI = [0.71, 1.08],
p = 0.22, five studies, N = 409,131) and
colorectal cancer by fecal occult blood test (pooled OR = 0.87, 95% CI = [0.55,
1.38], p = .55, two studies, N = 2,718) were
not significantly lower in people with cognitive impairment or dementia.
Conclusion: These historical rates provide a baseline for
discussions around the need for more specific guidance to assist with decisions
to discontinue screening. The study also identifies a gap in reported knowledge
with respect to screening under current guidelines.
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Affiliation(s)
- Marcus Law
- University of Toronto, Toronto, Ontario, Canada.,Michael Garron Hospital, Toronto, Ontario, Canada
| | | | - Nathan Herrmann
- University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Ayan K Dey
- University of Toronto, Toronto, Ontario, Canada.,Heart & Stroke Foundation Canadian Partnership for Stroke Recovery, Toronto, Ontario, Canada.,Baycrest Hospital, Toronto, Ontario, Canada
| | - Abby Li
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | | | - Jodi D Edwards
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Walter Swardfager
- University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,Heart & Stroke Foundation Canadian Partnership for Stroke Recovery, Toronto, Ontario, Canada.,Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
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27
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Housten AJ, Pappadis MR, Krishnan S, Weller SC, Giordano SH, Bevers TB, Volk RJ, Hoover DS. Resistance to discontinuing breast cancer screening in older women: A qualitative study. Psychooncology 2018; 27:1635-1641. [PMID: 29575590 PMCID: PMC5986612 DOI: 10.1002/pon.4708] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 03/07/2018] [Accepted: 03/09/2018] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Screening mammography is associated with reduced breast cancer-specific mortality; however, among older women, evidence suggests that the potential harms of screening may outweigh the benefits. We used a qualitative approach to examine the willingness of older women from different racial/ethnic groups to discontinue breast cancer screening. METHODS Women ≥70 years of age who reported having a screening mammogram in the past 3 years and/or reported that they intended to continue screening in the future were recruited for in-depth interviews. Participants who intended to continue screening were asked to describe how the following hypothetical scenarios would impact a decision to discontinue screening: health concerns or limited life expectancy, a physician's recommendation to discontinue, reluctance to undergo treatment, and recommendations from experts or governmental panels to stop screening. Semi-structured, face-to-face interviews were audio-recorded. Data coding and analysis followed inductive and deductive approaches. RESULTS Regardless of the scenario, participants (n = 29) expressed a strong intention to continue screening. Based on the hypothetical physician recommendations, intentions to continue screening appeared to remain strong. They did not envision a change in their health status that would lead them to discontinue screening and were skeptical of expert/government recommendations. There were no differences observed according to age, race/ethnicity, or education. CONCLUSIONS Among older women who planned to continue screening, intentions to continue breast cancer screening appear to be highly resilient and resistant to recommendations from physicians or expert/government panels.
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Affiliation(s)
- Ashley J Housten
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Monique R Pappadis
- Division of Rehabilitation Sciences, School of Health Professions, The University of Texas Medical Branch, Galveston, TX, USA
- Sealy Center on Aging, The University of Texas Medical Branch, Galveston, TX, USA
| | - Shilpa Krishnan
- Sealy Center on Aging, The University of Texas Medical Branch, Galveston, TX, USA
- Department of Occupational Therapy, School of Health Professions, The University of Texas Medical Branch, Galveston, TX, USA
| | - Susan C Weller
- Sealy Center on Aging, The University of Texas Medical Branch, Galveston, TX, USA
- Department of Preventive Medicine and Community Health, The University of Texas Medical Branch, Galveston, TX, USA
- Department of Family Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Therese B Bevers
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert J Volk
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Diana S Hoover
- Department of Health Disparities Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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28
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Lewis CL, Kistler CE, Dalton AF, Morris C, Ferrari R, Barclay C, Brewer NT, Dolor R, Harris R, Vu M, Golin CE. A Decision Aid to Promote Appropriate Colorectal Cancer Screening among Older Adults: A Randomized Controlled Trial. Med Decis Making 2018; 38:614-624. [DOI: 10.1177/0272989x18773713] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background. Concerns have been raised about both over- and underutilization of colorectal cancer (CRC) screening in older patients and the need to align screening behavior with likelihood of net benefit. Objective. The purpose of this study was to test a novel use of a patient decision aid (PtDA) to promote appropriate CRC screening in older adults. Methods. A total of 424 patients ages 70 to 84 y who were not up to date with CRC screening participated in a double-blinded randomized controlled trial of a PtDA targeted to older adults making decisions about whether to undergo CRC screening from March 2012 to February 2015. Intervention. Patients were randomized to a targeted PtDA or an attention control. The PtDA was designed to facilitate individualized decision making—helping patients understand the potential risks, benefits, and uncertainties of CRC screening given advanced age, health state, preferences, and values. Outcomes. Two composite outcomes, appropriate CRC screening behavior 6 mo after the index visit and appropriate screening intent immediately after the visit, were defined as completed screening or intent for patients in good health, discussion about screening with their provider for patients in intermediate health, and no screening or intent for patients in poor health. Health state was determined by age and Charlson Comorbidity Index. Results. Four hundred twelve (97%) and 421 (99%) patients were analyzed for the primary and secondary outcomes, respectively. Appropriate screening behavior at 6 mo was higher in the intervention group (55% v. 45%, P = 0.023) as was appropriate screening intent following the provider visit (61% v. 47%, P = 0.003). Limitations. The study took place in a single geographic region. The appropriate CRC screening classification system used in this study has not been formally validated. Conclusions. A PtDA for older adults promoted appropriate CRC screening behavior and intent. Trial Registration: Clinicaltrials.gov, registration number NCT01575990. https://clinicaltrials.gov/ct2/show/NCT01575990?term=epic-d&rank=1
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Affiliation(s)
- Carmen L. Lewis
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Christine E. Kistler
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alexandra F. Dalton
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Carolyn Morris
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Renée Ferrari
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Colleen Barclay
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Noel T. Brewer
- Department of Health Behavior, Gillings School of Global Health, and Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rowena Dolor
- Division of General Internal Medicine, Department of Medicine, Duke School of Medicine, Durham, NC, USA
| | - Russell Harris
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maihan Vu
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carol E. Golin
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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29
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Kotwal AA, Schonberg MA. Cancer Screening in the Elderly: A Review of Breast, Colorectal, Lung, and Prostate Cancer Screening. Cancer J 2018; 23:246-253. [PMID: 28731949 PMCID: PMC5608027 DOI: 10.1097/ppo.0000000000000274] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Ashwin A. Kotwal
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Mara A. Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Hamashima C, Sano H. Association between age factors and strategies for promoting participation in gastric and colorectal cancer screenings. BMC Cancer 2018; 18:345. [PMID: 29587681 PMCID: PMC5870209 DOI: 10.1186/s12885-018-4244-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 03/19/2018] [Indexed: 11/21/2022] Open
Abstract
Background Despite the long history of cancer screening in Japan, the participation rates in gastric and colorectal cancer screenings have not increased. Strategies for improving the participation rates have been proposed, but differences in their effects among different age groups remain unclear. Methods The Japanese government conducted a national survey in all municipalities in Japan in 2010 to investigate whether the implementation of promotion strategies increased participation in cancer screening. We investigated the association between age factors and strategies for promoting participation in cancer screening based on this national survey. Multiple regression analysis with generalized linear model was performed using the participation rates in gastric and colorectal cancer screenings as dependent variables, and the following strategies for promoting participation as independent variables: 1) personal invitation letters, 2) household invitation letters, 3) home visits by community nurses, 4) screenings in medical offices, and 5) free cancer screening programs. Results One thousand six hundred thirty nine municipalities for gastric cancer screening and 1666 municipalities for colorectal cancer screening were selected for the analysis. In gastric and colorectal cancer screenings, the participation rates of individuals aged 60–69 years was higher than those of other age groups. Personal and household invitation letters were effective promotion strategies for all age groups, which encouraged even older people to participate in gastric and colorectal cancer screenings. Screening in medical offices and free screenings were not effective in all age groups. Home visits were effective, but their adoption was limited to small municipalities. Conclusions To clarify whether promotion strategies can increase the participation rate in cancer screening among different age groups, 5 strategies were assessed on the basis of a national survey. Although personal and household invitation letters were effective strategies for promoting participation in cancer screening for all age groups, these strategies equally encouraged older people to participate in gastric and colorectal cancer screenings. If resource for sending invitation letters are limited, priority should be given to individuals who are in their 50s and 60s for gastric and colorectal cancer screening.
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Affiliation(s)
- Chisato Hamashima
- Division of Cancer Screening Assessment and Management, Center for Public Health Science, National Cancer Center, 5-1-1 Tsukiji Chuo-ku, Tokyo, 104-0045, Japan.
| | - Hiroshi Sano
- Faculty of Economics, Shiga University, 1-1-1 Baba-cho, Hikone, Japan
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Schoenborn NL, Cayea D, McNabney M, Ray A, Boyd C. Prognosis communication with older patients with multimorbidity: Assessment after an educational intervention. GERONTOLOGY & GERIATRICS EDUCATION 2017; 38:471-481. [PMID: 26885757 PMCID: PMC5826548 DOI: 10.1080/02701960.2015.1115983] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
This study aimed to assess how internal medicine residents incorporated prognosis to inform clinical decisions and communicated prognosis in primary care visits with older patients with multimorbidity after an educational intervention, and resident and patient perspectives regarding these visits. Assessment used mixed-methods. The authors assessed the frequency and content of prognosis discussions through residents' self-report and qualitative content analysis of audio-recorded clinic visits. The authors assessed the residents' perceived effect of incorporating prognosis on patient care and patient relationship through a resident survey. The authors assessed the patients' perceived quality of communication and trust in physicians through a patient survey. The study included 21 clinic visits that involved 12 first-year residents and 21 patients. Residents reported incorporating patients' prognoses to inform clinical decisions in 13/21 visits and perceived positive effects on patient care (in 11/13 visits) and patient relationship (in 7/13 visits). Prognosis communication occurred in 9/21 visits by self-report, but only in six of these nine visits by content analysis of audio-recordings. Patient ratings were high regardless of whether or not prognosis was communicated. In summary, after training, residents often incorporated patients' prognoses to inform clinical decisions, but sometimes did so without communicating prognosis to the patients. Residents and patients reported positive perceptions regarding the visits.
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Affiliation(s)
- Nancy L. Schoenborn
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine
| | - Danelle Cayea
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine
| | - Matthew McNabney
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine
| | - Anushree Ray
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine
- Ms. Ray was working as research assistant during this project at the Johns Hopkins School of Medicine but has since moved. She currently works as project manager at Medline Industries
| | - Cynthia Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine
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Schoenborn NL, Lee K, Pollack CE, Armacost K, Dy SM, Bridges JFP, Xue QL, Wolff AC, Boyd C. Older Adults' Views and Communication Preferences About Cancer Screening Cessation. JAMA Intern Med 2017; 177:1121-1128. [PMID: 28604917 PMCID: PMC5564296 DOI: 10.1001/jamainternmed.2017.1778] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
| | - Kimberley Lee
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Craig E Pollack
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Karen Armacost
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sydney M Dy
- The Johns Hopkins University School of Public Health, Baltimore, Maryland
| | - John F P Bridges
- The Johns Hopkins University School of Public Health, Baltimore, Maryland
| | - Qian-Li Xue
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Antonio C Wolff
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cynthia Boyd
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Ivlev I, Hickman EN, McDonagh MS, Eden KB. Use of patient decision aids increased younger women's reluctance to begin screening mammography: a systematic review and meta-analysis. J Gen Intern Med 2017; 32:803-812. [PMID: 28289963 PMCID: PMC5481237 DOI: 10.1007/s11606-017-4027-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 02/07/2017] [Accepted: 02/21/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND As breast cancer screening guidelines have changed recently, additional investigation is needed to understand changes in women's behavior after using breast cancer screening patient decision aids (BCS-PtDAs) and the potential effect on mammography utilization. This systematic review and meta-analysis sought to evaluate the effect of BCS-PtDAs on changes in women's intentions to undergo screening mammography and whether women deciding to begin or discontinue screening mammography displayed similar changes in screening intentions after using a BCS-PtDA. METHODS We searched Medline, Scopus, PsycINFO, CENTRAL, Health and Psychosocial Instruments, Health Technology Assessment Database, PsycARTICLES, and cited references in eligible papers for randomized controlled trials (RCTs) and observational studies, published through August 24, 2016. The proportions of women who did and not intend to undergo screening and who were uncertain about undergoing screening mammography were pooled, using risk ratios (RR) and random effects. According to the protocol, RCTs or observational studies and any language were considered eligible for systematic review if they included data about women for which shared decision making is recommended. RESULTS We ultimately included six studies with screening intention data for 2040 women. Compared to usual care, the use of BCS-PtDAs in three RCTs resulted in significantly more women deciding not to undergo screening mammography (RR 1.48 [95% CI 1.04-2.13]; P = 0.03), particularly for younger (38-50 years) women (1.77 [1.34-2.34]; P < 0.001). The use of BCS-PtDAs had a non-significant effect on the intentions of older women (69-89 years) to discontinue screening. CONCLUSIONS The use of BCS-PtDAs increased younger women's reluctance to undergo screening for breast cancer. The implementation of such BCS-PtDAs in clinical practice would be expected to result in a 77% increase in the number of younger women (aged 38-50) who do not intend to be screened, and as a consequence, may reduce utilization of screening mammography. REGISTRATION The protocol of this review is registered in the PROSPERO database, #CRD42016036695.
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Affiliation(s)
- Ilya Ivlev
- Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA.
| | - Erin N Hickman
- Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Marian S McDonagh
- Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Karen B Eden
- Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
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Cancer Screening in the Elderly: A Review of Breast, Colorectal, Lung, and Prostate Cancer Screening. Cancer J 2017. [DOI: 10.1097/00130404-201707000-00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pollack CE, Blackford AL, Schoenborn NL, Boyd CM, Peairs KS, DuGoff EH. Comparing Prognostic Tools for Cancer Screening: Considerations for Clinical Practice and Performance Assessment. J Am Geriatr Soc 2016; 64:1032-8. [PMID: 27131231 DOI: 10.1111/jgs.14089] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To compare the agreement and rates of cancer screening using four prognostic tools that require different types of clinical information. DESIGN Observational retrospective cohort study. SETTING 2009 and 2010 waves of the Medicare Current Beneficiary Survey. PARTICIPANTS Adults aged 66-90 with survey and claims data (N = 9,469). MEASUREMENTS Agreement between four indices predicting short-term (4-5 years) and long-term (9-10 years) survival; self-reported breast and prostate cancer screening. RESULTS Agreement between the four prognostic tools was high. Pearson correlation coefficients ranged from 0.63 to 0.90 for short-term survival and 0.68 to 0.94 for long-term survival. When defining limited short-term life expectancy as less than 25% chance of surviving 4 or 5 years, all four tools agreed in 96.4% of the sample. All four tools agreed in their placement of participants into limited or not-limited long-term life expectancy in 77.1% of participants (<25% chance of surviving 9 or 10 years). Rates of cancer screening were similarly high in individuals with limited long-term life expectancy regardless of the tool used: greater than 31% for mammographic screening in women and greater than 69% for prostate cancer screening. CONCLUSION There is substantial agreement among different prognostic tools for short- and long-term survival in Medicare beneficiaries. The high rates of cancer screening of individuals with limited life expectancy suggest the importance of incorporating tools into clinical decision-making.
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Affiliation(s)
- Craig Evan Pollack
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland.,Department of Oncology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Amanda L Blackford
- Department of Oncology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Nancy L Schoenborn
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Cynthia M Boyd
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Kimberly S Peairs
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Eva H DuGoff
- Department of Population Health Sciences, University of Wisconsin, Madison, Wisconsin
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Dolezil D, Haase A, Jahnke K, Thonack J, Löffler C, Schmidt CO, Chenot JF. [Cancer screening in the elderly: Explorative mixed methods study]. Z Gerontol Geriatr 2015; 49:44-51. [PMID: 26108994 DOI: 10.1007/s00391-015-0920-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 04/20/2015] [Accepted: 05/21/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The benefits of cancer screening in the elderly are uncertain. While the risk of cancer increases with age the participation in cancer screening decreases. AIM The study investigated the attitudes of older adults towards cancer screening as well as their motives for or against participation. MATERIAL AND METHODS This population-based explorative mixed methods study was based on a survey of residents aged 69-89 years from the district of Western Pomerania-Greifswald (northeast Germany). Criteria for exclusion were cognitive deficits and/or cancer. Attitudes towards different statements regarding cancer screening were assessed by a questionnaire using 5-point Likert scales. Semi-structured interviews were used to explore the motivations. RESULTS Out of 630 contacted residents, 120 (19%) with an average age of 77 years (SD ± 6 years) participated in the face-to-face survey. The majority were in favor of lifelong cancer screening, 14% stated other health problems to be more important than cancer screening and 7% assumed that they would not live long enough to benefit from screening. Motives for participation in cancer screening were habit, regularity, sense of obligation, fear and belief in benefits. Motives for discontinuing screening included a lack of interest, no assumed necessity and fear. Disadvantages were not feared. CONCLUSION Elderly people show great trust in cancer screening. They overestimated the benefits of cancer screening and their risk to die of cancer. The elderly should be better informed about the benefits and risks of cancer screening. Shared decision-making should be based on life expectancy and personal preferences.
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Affiliation(s)
- Doris Dolezil
- Abteilung Allgemeinmedizin, Institut für Community Medicine, Universitätsmedizin Greifswald KdöR, Fleischmannstr. 42-44, 17475, Greifswald, Deutschland
| | - Annekathrin Haase
- Abteilung Allgemeinmedizin, Institut für Community Medicine, Universitätsmedizin Greifswald KdöR, Fleischmannstr. 42-44, 17475, Greifswald, Deutschland.
| | - Kristine Jahnke
- Abteilung Allgemeinmedizin, Institut für Community Medicine, Universitätsmedizin Greifswald KdöR, Fleischmannstr. 42-44, 17475, Greifswald, Deutschland
| | - Jens Thonack
- Abteilung Allgemeinmedizin, Institut für Community Medicine, Universitätsmedizin Greifswald KdöR, Fleischmannstr. 42-44, 17475, Greifswald, Deutschland
| | - Christin Löffler
- Institut für Allgemeinmedizin, Universitätsmedizin Rostock, Rostock, Deutschland
| | - Carsten Oliver Schmidt
- Abteilung Study of Health in Pomerania - Klinisch-epidemiologische Forschung (Shinterviewpartner-KEF), Institut für Community Medicine, Universitätsmedizin Greifswald, Greifswald, Deutschland
| | - Jean-François Chenot
- Abteilung Allgemeinmedizin, Institut für Community Medicine, Universitätsmedizin Greifswald KdöR, Fleischmannstr. 42-44, 17475, Greifswald, Deutschland
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Abstract
Deciding when to stop cancer screening in older adults is a complex challenge that involves multiple factors: individual health status and life expectancy; risks and benefits of screening, which vary with age and comorbidity; and individual preferences and values. This article examines current cancer screening practices and reviews the risks and benefits of cancer screening for colorectal, breast, lung, prostate, and cervical cancer, particularly in older individuals and those with multiple comorbidities. Tools for estimating life expectancy are reviewed, and a practical framework is presented to guide discussions on when the harms of screening likely outweigh the benefits.
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Affiliation(s)
- Michael C Soung
- General Internal Medicine, Internal Medicine Residency Core Faculty, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA 98101, USA.
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Kistler CE, Hess TM, Howard K, Pignone MP, Crutchfield TM, Hawley ST, Brenner AT, Ward KT, Lewis CL. Older adults' preferences for colorectal cancer-screening test attributes and test choice. Patient Prefer Adherence 2015; 9. [PMID: 26203233 PMCID: PMC4508065 DOI: 10.2147/ppa.s82203] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Understanding which attributes of colorectal cancer (CRC) screening tests drive older adults' test preferences and choices may help improve decision making surrounding CRC screening in older adults. MATERIALS AND METHODS To explore older adults' preferences for CRC-screening test attributes and screening tests, we conducted a survey with a discrete choice experiment (DCE), a directly selected preferred attribute question, and an unlabeled screening test-choice question in 116 cognitively intact adults aged 70-90 years, without a history of CRC or inflammatory bowel disease. Each participant answered ten discrete choice questions presenting two hypothetical tests comprised of four attributes: testing procedure, mortality reduction, test frequency, and complications. DCE responses were used to estimate each participant's most important attribute and to simulate their preferred test among three existing CRC-screening tests. For each individual, we compared the DCE-derived attributes to directly selected attributes, and the DCE-derived preferred test to a directly selected unlabeled test. RESULTS Older adults do not overwhelmingly value any one CRC-screening test attribute or prefer one type of CRC-screening test over other tests. However, small absolute DCE-derived preferences for the testing procedure attribute and for sigmoidoscopy-equivalent screening tests were revealed. Neither general health, functional, nor cognitive health status were associated with either an individual's most important attribute or most preferred test choice. The DCE-derived most important attribute was associated with each participant's directly selected unlabeled test choice. CONCLUSION Older adults' preferences for CRC-screening tests are not easily predicted. Medical providers should actively explore older adults' preferences for CRC screening, so that they can order a screening test that is concordant with their patients' values. Effective interventions are needed to support complex decision making surrounding CRC screening in older adults.
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Affiliation(s)
- Christine E Kistler
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Correspondence: Christine E Kistler, Department of Family Medicine, University of North Carolina at Chapel Hill, 590 Manning Drive – CB 7595, Chapel Hill, NC 27599, USA, Tel +1 919 395 8621, Fax +1 919 966 6126, Email
| | - Thomas M Hess
- Department of Psychology, North Carolina State University, Raleigh, NC, USA
| | - Kirsten Howard
- Institute for Choice, University of South Australia, Sydney, NSW, Australia
- School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Michael P Pignone
- Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of General Internal Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Trisha M Crutchfield
- Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sarah T Hawley
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Alison T Brenner
- Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kimberly T Ward
- Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carmen L Lewis
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Decision-making and cancer screening: a qualitative study of older adults with multiple chronic conditions. J Geriatr Oncol 2014; 6:93-100. [PMID: 25544380 DOI: 10.1016/j.jgo.2014.12.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 10/29/2014] [Accepted: 12/01/2014] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To understand how older persons with multiple chronic conditions (MCC) approach decisions about cancer screening. MATERIALS AND METHODS We conducted interviews with adults >65 years old with at least two chronic conditions who were taking ≥five medications daily. Patients were first asked how age and multimorbidity influence their cancer screening decisions. After showing them an educational prompt that explained the relationship between life expectancy and the benefits of cancer screening, respondents were then asked about screening in the context of specific health scenarios. Using grounded theory, three independent readers coded responses for salient themes. Sample size was determined by thematic saturation. RESULTS Most respondents (26 of 28) initially indicated that their overall health or medical conditions do not influence their cancer screening decisions. After viewing the educational prompt, respondents described two broad approaches to cancer screening in the setting of increasing age or multi-morbidity. The first was a "benefits versus harms" approach in which participants weighed direct health benefits (e.g. reducing cancer incidence or mortality) and harms (e.g. complications or inconvenience). The second was a heuristic approach. Some heuristics favored screening, such as a persistent belief in unspecified benefits from screening, value of knowledge about cancer status, and not wanting to "give up", whereas other heuristics discouraged screening, such as fatalism or a reluctance to learn about their cancer status. CONCLUSIONS When considering cancer screening, some older persons with MCC employ heuristics which circumvent the traditional quantitative comparison of risks and benefits, providing an important challenge to informed decision making.
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Pallis AG, Gridelli C, Wedding U, Faivre-Finn C, Veronesi G, Jaklitsch M, Luciani A, O'Brien M. Management of elderly patients with NSCLC; updated expert's opinion paper: EORTC Elderly Task Force, Lung Cancer Group and International Society for Geriatric Oncology. Ann Oncol 2014; 25:1270-1283. [PMID: 24638905 DOI: 10.1093/annonc/mdu022] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
Non-small-cell lung cancer (NSCLC) is a very common disease in the elderly population and its incidence in this particular population is expected to increase further, because of the ageing of the Western population. Despite this, limited data are available for the treatment of these patients and, therefore, the development of evidence-based treatment recommendations is challenging. In 2010, European Organization for Research and Treatment of Cancer (EORTC) took an initiative in collaboration with International Society of Geriatric Oncology (SIOG) and created an experts panel that provided an experts' opinion consensus paper for the management of elderly NSCLC patients. Since this publication, important new data are available and EORTC and SIOG recommended to update the 2010 recommendations. Besides recommendations for surgery, adjuvant chemotherapy and radiotherapy, treatment of locally advanced and metastatic disease, recommendations were expanded, to include data on patient preferences and geriatric assessment.
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Affiliation(s)
- A G Pallis
- Medical Department, European Organization for Research and Treatment of Cancer, Brussels, Belgium.
| | - C Gridelli
- Division of Medical Oncology, 'S.G. Moscati' Hospital-Avellino, Avellino, Italy
| | - U Wedding
- Department of Internal Medicine II, Jena University Hospital, Jena, Germany
| | | | - G Veronesi
- Lung Cancer Early Detection Unit, Division of Thoracic Surgery, European Institute of Oncology, Milano, Italy
| | - M Jaklitsch
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - A Luciani
- Department of Medical Oncology, S. Paolo Hospital, Milan, Italy
| | - M O'Brien
- The Royal Marsden NHS Foundation, Surrey, UK
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Craft M. Cancer screening in the older adult: issues and concerns. Nurs Clin North Am 2014; 49:251-61. [PMID: 24846471 DOI: 10.1016/j.cnur.2014.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Making individual recommendations for cancer screening in older adult patients may be difficult and time consuming, because of the need to incorporate complex issues of life expectancy, health status, risks and benefits, and individual values and wishes. In this article, current recommendations and related risks and benefits are summarized. Specific issues and concerns are addressed, with suggestions for strategies to assist older adults in making screening decisions.
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Affiliation(s)
- Melissa Craft
- University of Oklahoma Health Sciences Center College of Nursing, 1100 North Stonewall Avenue, Room 420, Oklahoma City OK 73117, USA.
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Drazer MW, Prasad SM, Huo D, Schonberg MA, Dale W, Szmulewitz RZ, Eggener SE. National trends in prostate cancer screening among older American men with limited 9-year life expectancies: Evidence of an increased need for shared decision making. Cancer 2014; 120:1491-8. [DOI: 10.1002/cncr.28600] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 12/23/2013] [Accepted: 12/25/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Michael W. Drazer
- Department of Medicine; University of Chicago Medical Center; Chicago Illinois
| | - Sandip M. Prasad
- Department of Urology; Medical University of South Carolina; Charleston South Carolina
| | - Dezheng Huo
- Department of Health Studies; University of Chicago Medical Center; Chicago Illinois
| | - Mara A. Schonberg
- Department of Medicine; Harvard Medical School; Boston Massachusetts
| | - William Dale
- Department of Medicine; University of Chicago Medical Center; Chicago Illinois
| | | | - Scott E. Eggener
- Section of Urology; University of Chicago Medical Center; Chicago Illinois
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von Wagner C, Macedo A, Campbell C, Simon AE, Wardle J, Hammersley V, Weller D, Waller J. Continuing cancer screening later in life: attitudes and intentions among older adults in England. Age Ageing 2013; 42:770-5. [PMID: 23999536 PMCID: PMC3942134 DOI: 10.1093/ageing/aft132] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: the rise in life expectancy, together with age-related increase in the incidence of most cancers, has led to mounting interest in cancer screening in older people. In England, routine invitations stop and an ‘opt-in’ (individual request) process is available from ages 71 to 76 years for breast and colorectal screening respectively. Little is known about public attitudes towards age-stoppage policy. Objective: this study examined public attitudes to current stoppage policy, information preferences and intentions to request screening beyond the age of routine invitations. Sample: participants (n = 927; age 60–74 years) were recruited as part of a TNS Research International survey and took part in home-based, computer-assisted interviews. Methods: measures included: (i) attitudes towards current stoppage policy, (ii) preference for communications about screening after the end of the routine invitation period and (iii) intention to opt-in. Results: the majority of respondents (78%) did not agree with age-based stoppage policies. Most (83%) wanted a strong recommendation to opt-in after this age, although the number who thought they would follow such a recommendation was much lower (27%). A majority of participants (54%) thought information on screening at older ages should come from their general practitioner (GP). Conclusion: this survey indicates that older people in England wish to continue to be actively invited for cancer screening, although only a minority think that they would ultimately take up the offer. Primary care may play a role in negotiating a shared decision that is based on individual circumstances.
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Affiliation(s)
- Christian von Wagner
- Department of Epidemiology and Public Health, Health Behaviour Research Centre, University College London, Gower Street, London WC1E 6BT, UK
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Torke AM, Schwartz PH, Holtz LR, Montz K, Sachs GA. Caregiver perspectives on cancer screening for persons with dementia: "why put them through it?". J Am Geriatr Soc 2013; 61:1309-14. [PMID: 23865814 DOI: 10.1111/jgs.12359] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To describe the perspectives of family caregivers toward stopping cancer screening tests for their relatives with dementia and identify opportunities to reduce harmful or unnecessary screening. DESIGN Focus group study. SETTING Alzheimer's Association support groups for family members of individuals with dementia. PARTICIPANTS Four focus groups including 32 caregivers (25 female; 24 white, 7 African American, one American/Indian; mean age 65.5, range 49-85). MEASUREMENTS Focus group transcripts were transcribed and analyzed using methods of grounded theory. RESULTS Caregivers considered decisions to stop cancer screening in terms of quality of life and burden on the patient and caregiver. Many described having to intervene in the patient's care to stop unnecessary or harmful screening, and others met resistance when they advocated for stopping. Physicians varied widely in their knowledge of dementia care and willingness to consider cessation of screening. CONCLUSION Many family caregivers wish to stop cancer screening tests as dementia progresses and are relieved when physicians bring it up. Caregivers are open to discussions of screening cessation that focus on quality of life, burdens, and benefits. Interventions are needed to increase caregiver and clinician discussion of screening cessation and to increase clinician awareness of the need to reconsider cancer screening in individuals with dementia.
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Affiliation(s)
- Alexia M Torke
- Indiana University Center for Aging Research, Indiana University, Indianapolis, Indiana 46202, USA.
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Torke AM, Schwartz PH, Holtz LR, Montz K, Sachs GA. Older adults and forgoing cancer screening: "I think it would be strange". JAMA Intern Med 2013; 173:526-31. [PMID: 23478883 PMCID: PMC3748399 DOI: 10.1001/jamainternmed.2013.2903] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Although there is a growing recognition that older adults and those with extensive comorbid conditions undergo cancer screening too frequently, there is little information about patients' perceptions regarding cessation of cancer screening. Information on older adults' views of screening cessation would be helpful both for clinicians and for those designing interventions to reduce overscreening. OBJECTIVE To obtain a deeper understanding of older adults' perspectives on screening cessation and their experiences communicating with clinicians about this topic. DESIGN Semistructured interview study. SETTING Senior health center affiliated with an urban hospital. PARTICIPANTS We interviewed 33 older adults presenting to a senior health center. Their median age was 76 years (range, 63-91 years). Of the 33 participants, 27 were women; 15 were African American, 16 were white, 1 was Asian, and 1 was American Indian. MAIN OUTCOME MEASURES We transcribed audio recordings of interviews and analyzed them using methods of grounded theory to identify themes and illustrative quotes. RESULTS Undergoing screening tests was perceived by participants as morally obligatory. Although many saw continued screening as a habit or custom not involving any decision, cessation of screening would require a major decision. Many asserted that they had never discussed screening cessation with their physicians or considered stopping on their own; some reported being upset when their physician recommended stopping. Although some would accept a physician's strong recommendation to stop, others thought that such a physician's recommendation would threaten trust or lead them to get another opinion. Participants were skeptical about the role of statistics and the recommendations of government panels in screening decisions but were more favorable toward stopping because of the balance of risks and benefits, complications, or test burdens. CONCLUSIONS AND RELEVANCE For many older adults, stopping screening is a major decision, but continuing screening is not. A physician's recommendation to stop may threaten patient trust. Effective strategies to reduce nonbeneficial screening may include discussion of the balance of risks and benefits, complications, or burdens.
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Affiliation(s)
- Alexia M Torke
- Indiana University Center for Aging Research, Indianapolis, IN 46202, USA.
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Eckstrom E, Feeny DH, Walter LC, Perdue LA, Whitlock EP. Individualizing cancer screening in older adults: a narrative review and framework for future research. J Gen Intern Med 2013; 28:292-8. [PMID: 23054920 PMCID: PMC3614148 DOI: 10.1007/s11606-012-2227-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 08/21/2012] [Accepted: 08/31/2012] [Indexed: 12/18/2022]
Abstract
Older adults often have multiple chronic conditions that may decrease additional life expectancy. Research evaluating the benefits and harms of screening must include consideration of competing morbidities and patient heterogeneity (beyond age), potentially increased harms of screening, and patient preferences. Other areas in need of additional research include the lack of evidence for older adults on the harms of screening tests; the overdiagnosis of disease; the burden of disease labeling; the effects of inaccurate test results; the harms of disease treatment; and harms related to prioritization of healthcare (e.g., for a particular patient, lifestyle counseling may be more important than screening). Nontraditional outcomes, such as the effects on family caregivers, are also relevant. Studies comparing trajectories of quality-adjusted survival with and without screening to assess net benefit are typically lacking. There is little evidence on the preferences of older adults for deciding whether to be screened, the process of being screened, and the health states associated with being or not being screened. To enhance the quality and quantity of evidence, older adults need to be enrolled in screening trials and clinical studies. Measures of functional status and health-related quality of life (HRQL) need to be included in trials, registries, and cohort studies. This article addresses these challenges, and presents a framework for what research is needed to better inform screening decisions in older adults.
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Affiliation(s)
- Elizabeth Eckstrom
- Department of Medicine, Division of General Internal Medicine & Geriatrics, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, L475, Portland, OR 97239, USA.
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How have we diagnosed early-stage lung cancer without radiographic screening? A contemporary single-center experience. PLoS One 2012; 7:e52313. [PMID: 23284984 PMCID: PMC3528766 DOI: 10.1371/journal.pone.0052313] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 11/16/2012] [Indexed: 11/30/2022] Open
Abstract
Background The National Lung Screening Trial (NLST), which demonstrated a reduction in lung cancer mortality, may result in widespread computed tomography (CT)-based screening of select populations. How early-stage lung cancer has been diagnosed without screening, and what proportion of these cases would be captured by a screening program modeled on the NLST, is not currently known. We therefore evaluated current patterns of early-stage lung cancer presentation. Methodology/Principal Findings We performed a single-institution retrospective analysis of patients diagnosed with stage I–II non-small cell lung cancer (NSCLC) from 2000–2009. Associations between patient and imaging characteristics were assessed using univariate and multivariate analyses. A total of 412 patients met criteria for analysis. Among those with available reason for initial imaging, the reason was symptoms in 51%, follow-up of other conditions in 43%, and screening in 6%. Reason for imaging was associated with race (P<0.001), insurance type (P = 0.005), and disease stage (P<0.001). Type of initial imaging was associated with reason for imaging (P<0.001), year (chest x-ray 67% in 2000–2004 vs. 49% in 2005–2009; P<0.001), and disease stage (P = 0.005). Among patients with available quantified smoking history, 48% were age 55–74 years and smoked 30-plus pack-years, therefore meeting NLST entry criteria. Conclusions/Significance Symptoms remain a dominant but declining reason for detection of early-stage NSCLC. The proportion of cases detected initially by CT scan without antecedent chest x-ray has increased considerably. Because as few as half of cases meet NLST eligibility criteria, clinicians should remain aware of the diverse circumstances of early-stage lung cancer presentation to expedite therapy.
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Salemink S, Dekker N, Kets CM, van der Looij E, van Zelst-Stams WAG, Hoogerbrugge N. Focusing on patient needs and preferences may improve genetic counseling for colorectal cancer. J Genet Couns 2012; 22:118-24. [PMID: 22914993 PMCID: PMC3553404 DOI: 10.1007/s10897-012-9519-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Accepted: 06/14/2012] [Indexed: 12/11/2022]
Abstract
During cancer genetic counseling, different items which counselors consider important are discussed. However, relatively little empirical evidence exists regarding the needs and preferences of counselees. In this study needs and preferences were assessed from counselees with a personal and/or family history of colorectal cancer (CRC), who were referred for genetic counseling regarding CRC. They received a slightly modified version of the QUOTE-GENEca questionnaire prior to their first visit to the Hereditary Cancer Clinic. Response rate was 60 % (48/80 participants). Counselees rated the importance of 45 items assessing their needs and preferences regarding the content and process of genetic counseling. Participants rated the items regarding discussion of information about their familial CRC risk (100 %) and preventive options (98 %) as important or very important. Fewer participants rated items concerning general information on genetics as important. Sensitive communication during counseling was considered very important by a large percentage of counselees. Generally, no major differences were seen between participants in relation to individual characteristics. Our data suggest that focusing on familial CRC risk and surveillance options, in combination with sensitive communication may lead to better satisfaction with genetic counseling.
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Affiliation(s)
- Simone Salemink
- Department of Human Genetics 836, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
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Pollack CE, Platz EA, Bhavsar NA, Noronha G, Green GE, Chen S, Carter HB. Primary care providers' perspectives on discontinuing prostate cancer screening. Cancer 2012; 118:5518-24. [PMID: 22517310 DOI: 10.1002/cncr.27577] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 02/28/2012] [Accepted: 03/07/2012] [Indexed: 01/12/2023]
Abstract
BACKGROUND Clinical guidelines recommend against routine prostate-specific antigen (PSA) screening for older men and for those with lower life expectancies. The authors of this report examined providers' decision-making regarding discontinuing PSA screening. METHODS A survey of primary providers from a large, university-affiliated primary care practice was administered. Providers were asked about their current screening practices, factors that influenced their decision to discontinue screening, and barriers to discontinuing screening. Bivariate and multivariable logistic regression analyses were used to examine whether taking age and/or life expectancy into account and barriers to discontinuing were associated with clinician characteristics and practice styles. RESULTS One hundred twenty-five of 141 providers (88.7%) participated in the survey. Over half (59.3%) took both age and life expectancy into account, whereas 12.2% did not consider either in their decisions to discontinue PSA screening. Providers varied in the age at which they typically stopped screening patients, and the majority (66.4%) reported difficulty in assessing life expectancy. Taking patient age and life expectancy into account was not associated with provider characteristics or practice styles. The most frequently cited barriers to discontinuing PSA screening were patient expectation (74.4%) and time constraints (66.4%). Black providers were significantly less likely than nonblack providers to endorse barriers related to time constraints and clinical uncertainty, although these results were limited by the small sample size of black providers. CONCLUSIONS Although age and life expectancy often figured prominently in decisions to use screening, providers faced multiple barriers to discontinuing routine PSA screening.
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Affiliation(s)
- Craig E Pollack
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland 21287, USA.
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Howard DH, Huang YL. Serious health events and discontinuation of routine cancer screening. Med Decis Making 2012; 32:627-35. [PMID: 22287535 DOI: 10.1177/0272989x11434600] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
UNLABELLED Recently revised US Preventive Services Task Force screening guidelines for colorectal, breast, and prostate cancer contain separate recommendations for persons younger than 75 years and those 75 years or older. Developing an understanding of whether and how patients discontinue screening is important for evaluating the potential benefits and drawbacks of age-delimited screening recommendations as a tool for reducing overdiagnosis rates. Using Surveillance, Epidemiology, and End RESULTS -Medicare data from 1998 to 2007, the authors identified a sample of 32,189 female and 27,669 male fee-for-service Medicare beneficiaries who received 2 consecutive breast or prostate screens, 1 year apart. They then estimated the impact of serious health events, such as heart attacks and strokes, on continuation of screening. Rescreening rates among beneficiaries who did not experience a serious health event were 78% for women and 82% for men. Rescreening rates among beneficiaries who experienced a serious health event were 55% for women and 57% for men. The rate ratios associated with a time-varying indicator for the 2-year period following a serious health event were 0.79 (95% confidence interval: 0.76 to 0.81); P < 0.001) for women and 0.87 (95% confidence interval: 0.85 to 0.89; P < 0.001) for men. Approximately one-third of patients and physicians discontinue or temporarily suspend screening for breast and prostate cancer following serious health events. Findings suggest that not all patients persist with screening until they die.
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Affiliation(s)
- David H Howard
- Department of Health Policy and Management, Emory University, Atlanta, GA (DHH, YLH)
| | - Ya-Lin Huang
- Department of Health Policy and Management, Emory University, Atlanta, GA (DHH, YLH)
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