Cancer Screening Decisions Among Older Adults with Limited Life Expectancies

Findings published in JAMA Network Open indicated that cancer screening decisions among older adults with limited life expectancy were not always informed or intentional and were subject to multiple complex factors.

Given these findings, researchers indicated that strategies that promote more deliberate decision-making may be necessary in cancer screening of older adults with limited life expectancy.

“Our results may help inform future interventions aimed at reducing over- screening in older adults with limited life expectancy,” the authors wrote.

Clinicians from 17 academic and community clinics affiliated with a large health system were interviewed, in addition to medical record-stimulated recall, and asked how they came to specific cancer screening decisions in 2 or 3 of their older adult patients with an estimated life expectancy of less than 10 years, including patients with and without recent screening. Patients were surveyed by phone.

In total, 25 primary care clinicians discussed 53 patients during medical record-stimulated recall; 46 patients and 1 caregiver participated in the survey. Ultimately, clinician interviews revealed 5 major themes:

• Cancer screening decisions were not always conscious, calculated decisions
• Electronic medical record alerts were connected with less intentional decision-making
• Cancer screening was not binary, and clinicians often considered other options to scale back screening without actually stopping altogether
• In addition to patient characteristics, clinicians were influenced by patient request and anecdotal experiences
• Influences outside of the primary care clinician-patient pair were important, such as from specialists and patients’ family or friends

“As cancer screening technology continues to evolve, with blood tests that can potentially detect multiple types of cancers, it is important to examine both the immediate and the long-term consequences from the screening test in the context of a patient’s life expectancy and competing risks of death,” the authors wrote.

The 47 survey participants were asked approximately 64 cancer screening decisions on the patient surveys. Overall, the participants did not recall approximately half (31 of 64) of their cancer screening decisions. Of those who had a 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”). Importantly, in most screening decisions that involved specialists (13 of 16), patients valued specialists’ recommendations over the recommendations of primary care clinicians.

“When the decisions were deliberate, they were affected not only by evidence-based factors such as patient age, health status, and family history but also by subjective factors such as the clinicians’ anecdotal experiences and the patients’ family and friends,” the authors wrote.

Notably, this study only included a relatively small number of participants affiliated with 1 health system and their views may not have been representative of all practice settings. Additionally, to get reciprocal perspectives from both patients and clinicians, researchers focused their medical record-stimulated recall discussions on patients who also responded to the telephone survey, whereas cancer screening decision-making may have been different in non-responder patients.

“Eliciting feedback from key stakeholders on how to feasibly incorporate these elements in interventions is a key next step,” the authors wrote

Reference:

Schoenborn NL, Massare J, Park R, Boyd CM, Choi Y, Pollack CE. Assessment of Clinician Decision-making on Cancer Screening Cessation in Older Adults With Limited Life Expectancy. JAMA Network Open. doi:10.1001/jamanetworkopen.2020.6772