Cancer screening is highly advised and of great importance for identifying hidden and early symptoms in the majority of the population; however, it may not be beneficial for older adults above a certain age threshold. Actually, possible harm from screening might outweigh benefits such as life expectancy extension for certain population. Now the concern is how clinicians will communicate this type of information to patients. An interview-type study with 40 community-dwelling adults (over 65 years old) assessed opinions and preferences about clinicians’ decisions and communication styles regarding cancer screening cessation.
Cancer screening detects pre-cancerous changes or cancer at an early stage when there is a better chance of treating it successfully. Screening is for individuals who do not have any cancer symptoms. However, in an older population, screening might expose the patient to unnecessary risk. As it takes years for most cancers to develop till it exposes individual to health risk, and given the fact that the rate of cell division and the metabolism in older individuals is slowed down, the risk of getting a life-threatening cancer at older age (over 75) is not so high. Clinical guidance recommends clinicians consider an estimation of life expectancy while making decision about cancer screening. However, according to recent studies, many older adults (approximately 55%) are still referred for cancer screening procedures. A recent study published in JAMA Internal Medicine explored the opinions of older patients about cancer screening cessation.
Researchers conducted 30-60 minute interviews of older individuals with a mean age of 75.7 years. All participants were able to understand study information and provide informed consent. To increase variability, participants were recruited from 4 clinical programs affiliated with an academic medical center, and were selected to represent a wide age range (eligibility age over 65), variable health status and life expectancy estimations. The interview questions were developed and previously tested on 10individuals, which were not included in the study. At the beginning of the study participants were educated about potential risks and benefits of screening procedures.It was explained that it may take up to 10 years for cancer to get to the point that it causes health problems, and someone with a life expectancy of 10 years or less may not benefit from screening. The questions during the interview were divided into two domains: decision-making and communication with the clinician. The decision-making questions addressed patient’s opinion about the cessation of cancer screening together with the consideration of health and life expectancy parameters. It also addressed the patient’s reaction to the decision to stop screening. The communication part contained different phrases used by a clinician to discuss screening cessation with a hypothetical patient.
19 of the 40 participants (47.5%) had a life-expectancy of fewer than 10 years and 8 had a life expectancy of fewer than 4 years. All participants had a high level of trust in their clinician (average score, 4.7 out of 5.0). Out of 29 participants with up-to-date cancer screening, 5 participants (all female) reported that they had decided to stop screening and 4 participants (2 males, 2 females) reported that they were unsure about continued screening.
The main reason to stop screening was age. One 84-year-old woman said: “I just feel like at my age I don’t need a colonoscopy, what’s gonna be is gonna be.”People also reported that “There was a lot of unnecessary anxiety associated with expectation for screening results” and “it feels good not to go through more screenings”. The proposed age threshold to stop screening varied from 65 to 100 years of age. Regarding the decision to stop screening being made by the clinician, most participants reported a positive reaction, attributing this to their trust and confidence in their clinician.
While many participants agreed that health status should be considered while making screening decisions, many did not understand the role of life expectancy and were uncomfortable discussing life expectancy with their clinicians. Some participants were sceptical about the ability to predict life expectancy and expressed that they would prefer to discuss their health status with their clinician, rather than their life expectancy. Some said “Even though the doctor may have the feeling that the patient is not going to live very long I don’t think he should express it… No, just say the test is not going to be helpful.”
Overall, the study results suggest that older patients are receptive to discussion about cancer screening cessation and trust their clinicians. However, the decision is better communicated through the health status discussion, rather than referencing limited life expectancy. Further research on a larger population is advised to support those recommendations.
Reference: Older Adults’ Views and Communication Preferences About Cancer Screening Cessation, Jama Internal Medicine, Nancy L. Schoenborn, MD et al
Written by Bella Groisman, PhD