Are We Choosing Wisely? Older Adults’ Cancer Screening Intentions and Recalled Discussions with Physicians About Stopping

Abstract

BACKGROUND: National guidelines recommend against cancer screening for older individuals with less than a 10year life expectancy, but it is unknown if this population desires ongoing screening. OBJECTIVE: To determine (1) if older individuals with < 10-year life expectancy have future intentions for cancer screening, (2) if they recall a doctor previously suggesting that screening is no longer needed, and (3) individual characteristics associated with intentions to seek screening. DESIGN: National Social life Health and Aging Project (2015-2016), a nationally representative, cross-sectional survey. PARTICIPANTS: Community-dwelling adults 55-97 years old (n = 3816). MAIN MEASURES: Self-reported: (1) mammography and PSA testing within the last 2 years, (2) future intentions to be screened, and (3) discussion with a doctor that screening is no longer needed. Ten-year life expectancy was estimated using the Lee prognostic index. Multivariate logistic regression analysis examined intentions to pursue future screening, adjusting for sociodemographic and health covariates. KEY RESULTS: Among women 75-84 with < 10-year life expectancy, 59% intend on future mammography and 81% recall no conversation with a doctor that mammography may no longer be necessary. Among men 75-84 with < 10-year life expectancy, 54% intend on future PSA screening and 77% recall no discussions that PSA screening may be unnecessary. In adjusted analyses, those reporting recent cancer screening or no recollection that screening may not be necessary were more likely to want future mammography or PSA screening (p < 0.001). CONCLUSION: Over 75% of older individuals with limited life expectancy intend to continue cancer screening, and less than 25% recall discussing with physicians the need for these tests. In addition to public health and education efforts, these results suggest that older adults' recollection of being told by physicians that screening is not necessary may be a modifiable risk factor for reducing overscreening in older adults with limited life expectancy.

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

“…22 Additionally, health professionals hesitate to inform patients about confusing potential harms such as overdiagnosis 23 and the majority (around 75%) of older American adults recall no conversation with a doctor that screening for breast or prostate cancer may no longer be necessary. 19 These conversations inherently involve sensitive and uncertain topics that clinicians feel uncomfortable to raise with their older patients. 24 25 A qualitative study interviewed 40 men and women aged 65 years and older to identify their preferences for communicating about discontinuing screening.…”

Primary care provider perspectives on screening mammography in older women: A qualitative study

“…All providers in our study noted time constraints as a limiting factor to having nuanced discussions with patients regarding screening mammography. These time limitations may not only explain the lack of communication between providers and patients about screening that has been reported in prior studies ( Kotwal et al, 2019 ), but may also account for the documented variability in rates of screening mammography utilization ( Martires et al, 2014 , Linder et al, 2014 ). Decision fatigue is a term that describes the phenomenon in which providers are more willing to order healthcare services of questionable utility later in the day when appointment time is limited.…”

“…Second, study findings reflect self-reported data from participants and may not accurately reflect their clinical practice, as prior work has demonstrated that PCP verbalized endorsement of shared decision-making does not always correspond to actual clinical practice. 47 Importantly, selection bias and/or response bias may have contributed to our finding that all interviewed providers frequently engaged in shared decision-making with their patients regarding screening mammography, as prior literature has demonstrated few patients recall engaging in such discussions with their PCP ( Kotwal et al, 2019 ). Finally, the majority of our participants were medical doctors and thus our data may not reflect the views of advanced practice providers.…”

“…This ambiguity leaves primary care providers (PCPs) with much uncertainty when it comes to recommending screening mammography for older patients. This is reflected in the wide variations in clinical practice in terms of patient counseling and mammography utilization, with high rates of mammography utilization among older women despite conflicting guidelines ( Haas et al, 2017 , Tan et al, 2014 , Onega et al, 2017 , Schonberg et al, 2013 , Schonberg et al, 2006 , Bhosle et al, 2007 , Martires et al, 2014 , Radhakrishnan et al, 2018 , Kotwal et al, 2019 ). In a 2018 population-based survey of North Carolina residents, 79.8% of women ages 50–74 reported having a mammogram in the last two years, while the rate was similar at 71.8% for women ages ≥75.…”

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

“…This may help ameliorate a key challenge to changing screening behavior: patients tend to overestimate the benefits and underestimate the potential harms of screening. 25 Mutual understanding of the purpose of screening at the time screening is first recommended, reiterated over time, will help facilitate meaningful end-of-screening discussions by reinforcing realistic risk/benefit expectations. Clinicians will also benefit from clinical practice guidelines with a framework for approaching screening decisions with patients, such as the Individualized Decisions for Screening framework proposed by Breslau et al 23 End-of-screening discussions can be time-consuming; including end-of-screening discussions in quality metrics will help ensure that health systems adjust scheduling expectations and compensation schemes to accommodate this.…”