Patient-Reported Factors Associated With Older Adults’ Cancer Screening Decision-making

Jenna Smith,Vasi Naganathan,Rachael H Dodd,Erin Cvejic,Kirsten J Mccaffery,Karen M Gainey,Jesse Jansen

doi:10.1001/jamanetworkopen.2021.33406

Abstract

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

Highlights

Decisions for older adults and their clinicians about cancer screening are not easy
62% Did not think physician’s life expectancy estimate was important in making cancer screening decisions 81% Agree with “I will likely die of some other disease besides cancer” 50% Agree with “As people get older, other health issues are more important than cancer screening” 44% Agree “People over 70 who are totally dependent on someone else for daily functions such as eating, bathing, and toileting should not get cancer screening” 44% Agree “People with Alzheimer's disease or dementia should not get cancer screening” No vs yes (OR, 3.809; P = .001)
72.6%; good or very good or excellent, 63.3%; P = 1.902 Yes, 55.3%; no, 73.9%; odds ratio (OR), 3.06; P = .015 Yes, 47.1%; no, 73.1%; OR, 3.13; P = .004 Positive screening attitudes: second most associated with decisions; patient 1-y life expectancy, 57.2% chose screening; 1-y life expectancy and age ≥75 y, 45.8% Not positive screening attitudes: third most associated; patients with prior screening were more likely to screen Not positive screening attitudes: fourth most associated; good or medium, more likely to choose screening vs poor quality of life

Summary

Introduction

Decisions for older adults (aged Ն65 years) and their clinicians about cancer screening are not easy. There has recently been a shift in cancer screening communication to support informed decision-making rather than persuasively promote uptake.[11] Some clinicians and researchers advocate for individualized screening decisions for older adults (ie, not solely based on age).[4,6] using these approaches in practice is challenging. Clinicians have varied knowledge about overscreening and find it difficult to discuss stopping screening.[12] some older adults may not appreciate a recommendation to stop screening,[13] and positive screening attitudes may be associated with continued screening.[14]

Methods

Results

Discussion

Conclusion