Despite current clinical practice guidelines recommending that clinicians use life expectancy to inform cancer screening, many older adults do not consider life expectancy to be an important factor in screening and prefer not to discuss it, according to findings published in JAMA Internal Medicine.
Using patient views and communication preferences about cancer screening cessation can inform discussions and optimize care, according to the researchers.
“Cancer screening in older adults with limited life expectancy may inappropriately subject them to short-term harms when chance of benefit is minimal,” Nancy L. Schoenborn, MD, from the Johns Hopkins University School of Medicine, and colleagues wrote.
“Clinicians’ recommendations are among the most influential factors in cancer screening decisions, and clinicians are frequently uncomfortable stopping cancer screening” and discussing life expectancy, they added.
Schoenborn and colleagues conducted a semistructured interview study of older adults aged 65 years or older to assess their views and preferences on deciding to cease cancer screening when life expectancy is limited and how clinicians should communicate such recommendations. They enrolled 40 community-dwelling older adults (average age, 75.7 years; 57.5% female; 62.5% white) from four clinical programs from an urban academic medical center. Nearly half of participants (47.5%) had an estimated life expectancy of less than 10 years. Transcripts of the interviews were evaluated using standard techniques of qualitative content analysis to identify major themes and subthemes.
The researchers found that participants were agreeable to considering stopping cancer screening, particularly when they reported having a high-level of trust with their clinician. Using age and health status to individualize screening decisions was supported by many older adults and they preferred clinicians to use such an approach; however, the role of life expectancy was often not understood and was more divisive. A majority of participants opposed a Choosing Wisely statement that recommended against cancer screening in those with limited life expectancy. These participants were skeptical that life expectancy could be accurately predicted by a clinician. How life expectancy was worded was important to participants. For example, the phrase “you may not live long enough to benefit from this test” was viewed as harsher than “this test would not help you live longer.”
“Our findings highlight a potential dilemma around incorporating life expectancy in cancer screening... Clinicians may be caught between, on the one hand, patients who do not believe or want to hear about life expectancy, and, on the other hand, research and guidelines that emphasize the importance of using life expectancy to inform cancer screening,” Schoenborn and colleagues concluded. “The scientific literature increasingly recognizes the importance of incorporating patient preference into clinical guidelines, including in the language of guideline presentation. Our results need to be tested in larger populations but suggest that misperceptions around the term life expectancy may be a barrier to guideline acceptance; a different term to represent the predicted health trajectory based on age and health status may be more preferred by patients.”
In an accompanying editorial, Alexia M. Torke, MD, MS, from the department of medicine at Indiana University, wrote that this is an important step in adding to the research of older adults’ views and communication preferences about cancer screening cessation.
“Further work could develop and test messages based on these findings with larger groups of patients and could aid in the design of new interventions to reduce nonbeneficial screening,” she wrote. – by Alaina Tedesco
Disclosure: Schoenborn and colleagues report funding from the National Institute on Aging of the National Institutes of Health and Maryland Cigarette Restitution Fund Research. Torke reports receiving support from the National Institute on Aging. Please see full study for complete list of all other authors’ relevant financial disclosures.