Exploring factors that might influence primary-care provider discussion of and recommendation for prostate and colon cancer screening

Kistler, Christine E.; Vu, Maihan B.; Sutkowi-Hemstreet, Anne; Gizlice, Ziya; Harris, Russell; Brewer, Noel T.; Lewis, Carmen L.; Dolor, Rowena J; Barclay, Colleen; Sheridan, Stacey

doi:10.2147/ijgm.s153887

Cited by 8 publications

(19 citation statements)

References 65 publications

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“…Although all 3 factors were independently associated with physician decision-making, health status had the largest effect, followed by patient age, and both patient age and health were more influential than adenoma risk. The importance of patient age and health status found in our study mirrors prior study results on physician decision-making regarding screening colonoscopies in older adults and makes intuitive sense (19–21). However, a sizable minority of physicians still would recommend surveillance even for patients in advanced age and/or poor health.…”

Section: Discussionsupporting

confidence: 85%

Physician Decision-Making About Surveillance in Older Adults With Prior Adenomas: Results From a National Survey

et al. 2023

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INTRODUCTION: There is no clear guidance on when surveillance colonoscopies should stop in older adults with prior adenomas. We aimed to examine physicians' decision-making regarding surveillance colonoscopies in older adults. METHODS:In a national mailed survey of 1,800 primary care physicians (PCP) and 600 gastroenterologists, we asked whether physicians would recommend surveillance colonoscopy in vignettes where we varied patient age (75 and 85 years), health (good, medium, and poor), and prior adenoma risk (low and high).We examined the association between surveillance recommendations and patient and physician characteristics using logistic regression. We also assessed decisional uncertainty, need for decision support, and decision-making roles.

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Section: Discussionsupporting

confidence: 85%

Physician Decision-Making About Surveillance in Older Adults With Prior Adenomas: Results From a National Survey

et al. 2023

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“… 55 Cancer screenings may depend on patient preference, which may lead to testing outside of clinical guidelines. 56 Within VHA, we were concerned that persistent testing outside guidelines may be associated with history of Vietnam-era Agent Orange exposure, a risk factor for prostate cancer. 34 However, a dedicated subgroup analysis did not show that this exposure was associated with more low-value testing.…”

Section: Discussionmentioning

confidence: 99%

“…We also did not include all cancer screening factors, such as encounter time, individual attitudes, or patient request. 12 , 56 We also note aspects that may limit external generalizability, including specific exclusion criteria, data missingness, and studying veterans in a national integrated health system.…”

Section: Discussionmentioning

confidence: 99%

Factors Associated With Low-Value Cancer Screenings in the Veterans Health Administration

et al. 2021

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IMPORTANCEMost clinical practice guidelines recommend stopping cancer screenings when risks exceed benefits, yet low-value screenings persist. The Veterans Health Administration focuses on improving the value and quality of care, using a patient-centered medical home model that may affect cancer screening behavior. OBJECTIVE To understand rates and factors associated with outpatient low-value cancer screenings. DESIGN, SETTING, AND PARTICIPANTS This cohort study assessed the receipt of low-value cancer screening and associated factors among 5 993 010 veterans. Four measures of low-value cancer screening defined by validated recommendations of practices to avoid were constructed using administrative data. Patients with cancer screenings in 2017 at Veterans Health Administration primary care clinics were included. Excluded patients had recent symptoms or historic high-risk diagnoses that may affect test appropriateness (eg, melena preceding colonoscopy). Data were analyzed from December 23, 2019, to June 21, 2021. EXPOSURES Receipt of cancer screening test. MAIN OUTCOMES AND MEASURES Low-value screenings were defined as occurring for averagerisk patients outside of guideline-recommended ages or if the 1-year mortality risk estimated using a previously validated score was at least 50%. Factors evaluated in multivariable regression models included patient, clinician, and clinic characteristics and patient-centered medical home domain performance for team-based care, access, and continuity previously developed from administrative and survey data. RESULTS Of 5 993 010 veterans (mean [SD] age, 63.1 [16.8] years; 5 496 976 men [91.7%]; 1 027 836 non-Hispanic Black [17.2%] and 4 539 341 non-Hispanic White [75.7%] race and ethnicity) enrolled in primary care, 903 612 of 4 647 479 men of average risk (19.4%) underwent prostate cancer screening; 299 765 of 5 770 622 patients of average risk (5.2%) underwent colorectal cancer screening; 21 930 of 469 045 women of average risk (4.7%) underwent breast cancer screening; and 65 511 of 458 086 women of average risk (14.3%) underwent cervical cancer screening. Of patients screened, low-value testing was rare for 3 cancers, with receipt of a low-value test in 633 of 21 930 of women screened for breast cancer (2.9%), 630 of 65 511 of women screened for cervical cancer (1.0%), and 6790 of 299 765 of patients screened for colorectal cancer (2.3%). However, 350 705 of 4 647 479 of screened men (7.5%) received a low-value prostate cancer test. Patient race and ethnicity, sociodemographic factors, and illness burden were significantly associated with likelihood of receipt of low-value tests among screened patients. No single patient-, clinician-, or clinic-level factor explained the receipt of a low-value test across cancer screening cohorts.

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“…This study adds to the existing literature on clinician decision-making about cancer screening in older adults using the method of medical record-stimulated recall, simultaneously eliciting perspectives from clinicians and patients, and focusing on screening cessation in older adults with limited life expectancy. Previous interview and survey studies examined factors important to clinicians in cancer screening decisions, [22][23][24][25][26][27][28][30][31][32] which by study design asked the participants to deliberately reflect on the decision-making process. This study examined actual decisions made with specific patients, and found that screening decisions were often not the results of conscious deliberation.…”

Section: Discussionmentioning

confidence: 99%

“…Further, previous research often relied on the use of hypothetical scenarios which may not reflect actual decision-making and behavior. 22,23,26,[30][31][32] In addition, as the decision to stop screening involves interaction between clinicians and patients, simultaneous investigation of both perspectives can offer important insights but has not been previously examined.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2020

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IMPORTANCE Despite clinical practice guidelines recommending against routine cancer screening in older adults with limited life expectancy, older adults are still frequently screened for breast, colorectal, and prostate cancers. OBJECTIVE To examine primary care clinicians' decision-making on stopping breast, colorectal, or prostate cancer screening in older adults with limited life expectancy. DESIGN, SETTING, AND PARTICIPANTSIn qualitative interviews coupled with medical recordstimulated recall, clinicians from 17 academic and community clinics affiliated with a large health system were asked how they came to specific cancer screening decisions in 2 or 3 of their older patients with less than 10-year of estimated life expectancy, including patients with and without recent screening. Patients were surveyed by telephone. Data collection occurred between October 2018 and May 2019. MAIN OUTCOMES AND MEASURESClinician interviews were audio-recorded and transcribed verbatim. Transcripts were analyzed with qualitative content analysis to identify major themes. Patient surveys assessed perception of cancer screening decisions, importance of clinician recommendation, and willingness to stop screening. RESULTS Twenty-five primary care clinicians (mean [SD] age, 47.1 [9.7] years; 14 female [56%]) discussed 53 patients during medical record-stimulated recall, ranging from 2 to 3 patients per clinician; 46 patients and 1 caregiver (mean [SD] age 74.9 [5.4]; 31 female [66%]) participated in the survey. Clinician interviews revealed 5 major themes: (1) cancer screening decisions were not always conscious, deliberate decisions; (2) electronic medical record alerts were connected with less deliberate decision-making; (3) cancer screening was not binary and clinicians often considered other options to scale back screening without actually stopping; (4) in addition to patient characteristics, clinicians were influenced by patient request and anecdotal experiences; and (5) influences outside of the primary care clinician-patient dyad were important, such as from specialists and patients' family or friends. Patient surveys asked approximately 64 cancer screening decisions of 47 patients.Patients did not recall approximately half (31 of 64) of their cancer screening decisions. Among those with recent screening, the mean score for willingness to stop screening was 3.2 (95% CI 2.5-3.9) on a 5-point Likert scale (with 1 indicating "extremely unlikely" and 5 indicating "extremely likely"). In most screening decisions that involved specialists (13 of 16), patients valued specialists' recommendations over those of primary care clinicians. CONCLUSIONS AND RELEVANCECancer screening decision-making is complex. Study findings suggest that strategies that facilitate more deliberate decision-making may be important in cancer screening of older adults with limited life expectancy.

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Exploring factors that might influence primary-care provider discussion of and recommendation for prostate and colon cancer screening

Cited by 8 publications

References 65 publications

Physician Decision-Making About Surveillance in Older Adults With Prior Adenomas: Results From a National Survey

Physician Decision-Making About Surveillance in Older Adults With Prior Adenomas: Results From a National Survey

Factors Associated With Low-Value Cancer Screenings in the Veterans Health Administration

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

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