Older Adults and Forgoing Cancer Screening

Abstract

Importance: Although there is a growing recognition that older adults and those with extensive comorbid conditions undergo cancer screening too frequently, there is little information about patients' perceptions regarding cessation of cancer screening. Information on older adults' views of screening cessation would be helpful both for clinicians and for those designing interventions to reduce overscreening.Objective: To obtain a deeper understanding of older adults' perspectives on screening cessation and their experiences communicating with clinicians about this topic.Design: Semistructured interview study.Setting: Senior health center affiliated with an urban hospital. Participants:We interviewed 33 older adults presenting to a senior health center. Their median age was 76 years (range, 63-91 years). Of the 33 participants, 27 were women; 15 were African American, 16 were white, 1 was Asian, and 1 was American Indian. Main Outcome Measures:We transcribed audio recordings of interviews and analyzed them using methods of grounded theory to identify themes and illustrative quotes.Results: Undergoing screening tests was perceived by participants as morally obligatory. Although many saw continued screening as a habit or custom not involving any decision, cessation of screening would require a major decision. Many asserted that they had never discussed screening cessation with their physicians or considered stopping on their own; some reported being upset when their physician recommended stopping. Although some would accept a physician's strong recommendation to stop, others thought that such a physician's recommendation would threaten trust or lead them to get another opinion. Participants were skeptical about the role of statistics and the recommendations of government panels in screening decisions but were more favorable toward stopping because of the balance of risks and benefits, complications, or test burdens.Conclusions and Relevance: For many older adults, stopping screening is a major decision, but continuing screening is not. A physician's recommendation to stop may threaten patient trust. Effective strategies to reduce nonbeneficial screening may include discussion of the balance of risks and benefits, complications, or burdens.

Adult Patients’ Perspectives on the Benefits and Harms of Overused Screening Tests: a Qualitative Study

“…Our study supports prior conclusions that patients are enthusiastic about screening 14,15 , and consider it something to be done even when the medical community deems it to have net harm or marginal benefit 17, [19][20][21] . Further, our study builds on prior work about patients' perspectives on potentially harmful tests 49,50 , demonstrating a misunderstanding of the benefits and incomplete knowledge of the harms of screening tests.…”

“…Even after reading information about harms, the majority of patients wanted screening, and many said they would rely on heuristics to make these decisions. Given similar findings in other studies 15 , interventionists could consider evaluating new heuristics, such as Bnot all screening tests are the same^or Bsome screening tests can be harmful,^that might prompt patients to appropriately consider each screening test on its own merit. Furthermore, patients may need assistance in identifying the best information for decision-making, given the often conflicting information from family, friends, or the media, which complicates efforts within the medical community to reduce overuse.…”

“…Because patients are often unrealistically enthusiastic about screening 14 , a key component of any reduction strategy should be understanding patients' perspectives, needs, and concerns specifically about overused services. To date, however, few studies have explored whether and how patients generally think about the harms and benefits of overused screening tests, or how patients use other factors to come to a decision about whether to receive these tests 15 .…”

An Individualized Approach to Cancer Screening Decisions in Older Adults: A Multilevel Framework

“…20,21 In addition, the desire to live longer might motivate screening, 14 while preparation for the end of life might preclude cancer screening. 14,15,17 In general, however, life expectancy does not seem to weigh heavily in patients' screening decisions. Related anxiety 23,24 and the need for reassurance 14,17 are other psychosocial influences that affect patient's choices.…”

“…Related anxiety 23,24 and the need for reassurance 14,17 are other psychosocial influences that affect patient's choices. 15,24 ii. Clinician factors that influence individualized decisions…”