A Novel Curriculum on Using Life Expectancy to Inform Cancer Screening in Older Adults

Abstract

BACKGROUND: Many older adults with limited life expectancy still receive cancer screening. One potential contributor is that primary care providers (PCP) are not trained to incorporate life expectancy in cancer screening recommendations. We describe the development and evaluation of a novel curriculum to address this need. METHODS: We developed and implemented a web-based learning module within a large Maryland group practice with PCPs for older adults. We assessed attitude, knowledge, self-efficacy, and self-reported behavior outcomes before the module, immediately after completing the module, and 6 months afterwards. RESULTS: Of 172 PCPs who were invited, 86 (50%) completed the module and of these, 50 (58.1%) completed the 6-months follow up survey. Immediately after the module, there was a significant increase in perceived importance of life expectancy (increase of 0.50 point on 10-point scale, 95% confidence intervals (CI) = 0.27-0.73), confidence in predicting life expectancy (increase of 2.32 points on 10-point scale, 95% CI = 1.95-2.70) and confidence in discussion screening cessation (increase of 1.69 points on 10-point scale, 95% CI = 1.37-2.02). Knowledge in patient-preferred communication strategies improved from 55% correct response to 97% (P < .001). However, most of these improvements dissipated by 6 months and there was no change in self-reported behavior at 6 months compared to baseline (P = .34). CONCLUSION: Although the module resulted in significant short-term improvement in attitude, knowledge, and self-efficacy, the changes were not sustained over time. Educational interventions such as this can be coupled with ongoing reinforcing strategies and/or decision support interventions to improve cancer-screening practices in older adults.

Perceived Barriers Among Clinicians and Older Adults Aged 65 and Older Regarding Use of Life Expectancy to Inform Cancer Screening: A Narrative Review and Comparison

“…Clinicians see prognosis as a difficult topic to talk about (Ahmed et al, 2021; Schoenborn, Bowman, Cayea, Pollack et al, 2016; Schonberg, Jacobson et al, 2020). Overall, they don’t know how best to communicate about life expectancy with older patients and are unsure how to navigate anticipated negative reactions.…”

“…Notably, clinicians do not feel they have had adequate training about how to use prognosis in medical school, residency, or as practicing physicians (Ahmed et al, 2021; Schoenborn, Bowman, Cayea, Pollack et al, 2016; Schonberg, Jacobson et al, 2020; Sifri et al, 2019). Although a web-based training intervention showed short-term improvements in clinician attitudes about the importance of life expectancy in cancer screening, their confidence estimating life expectancy, confidence in communicating a recommendation to stop cancer screening, and knowledge on preferred ways to discuss cancer screening, the effects of the intervention waned by 6 months (Ahmed et al, 2021).…”

“…Thomas et al (2018) found that clinicians who participated in focus groups about the scope of prognosis in the care of older adults also reported reservations about using mortality risk or life expectancy to make care management decisions (Thomas & Fried, 2018). A consistent finding across studies is that clinicians consider multiple clinical and individual factors to be important when evaluating whether an older patient is likely to benefit from continued cancer screening (Ahmed et al, 2021;Lewis et al, 2009Lewis et al, , 2013Moré et al, 2018;Schonberg, Jacobson et al, 2020;Schonberg, Karamourtopoulos et al, 2020;Sifri et al, 2019;Thomas & Fried, 2018), and clinicians have further concerns that life expectancy estimation models may be missing important predictor variables or ability to account for changes in patient status over time Thomas & Fried, 2018).…”

Strategies for discussing long‐term prognosis when deciding on cancer screening for adults over age 75

“…Dr. Schoenborn also developed an asynchronous curriculum to teach PCPs how to use life expectancy in deciding when to stop cancer screening in older adults. 39 The training led to an immediate increase in PCPs' self-efficacy to estimate patient life expectancy and to discuss stopping screening but no change in PCP behavior. These findings suggest that PCPs find longterm prognosis estimates useful but will likely need to learn, discuss, role play, and practice some of the strategies we have identified to go beyond estimating prognosis to actually discussing long-term prognosis with older adults.…”

“…Long-term prognosis discussions are increasingly recommended for high quality patient-centered care of older adults. 36,39 Figure 2 provides a visual summary of our findings including a summary of factors that increase the likelihood of productive long-term prognosis conversations with older adults and suggestions to clinicians on how to begin and conduct these conversations. Future studies will need to test the effect of these strategies in diverse practices.…”