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

Abstract

IMPORTANCE Decisions for older adults (aged Ն65 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. OBJECTIVETo summarize the patient-reported factors associated with older adults' decisions regarding screening for breast, prostate, colorectal, and cervical cancer.EVIDENCE REVIEW 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. FINDINGSThe 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. CONCLUSIONS AND RELEVANCEAlthough 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.

Women's experiences of age‐related discontinuation from mammography screening: A qualitative interview study

“… 28 , 30 , 41 , 42 , 43 , 44 Literature also supports that lay people generally overestimate the benefits of participation. 23 , 26 , 27 , 45 A Danish study examined responses to mammography screening and revealed that it provided feelings of reassurance for those participating, compared with women not invited to screening. 30 Another Danish interview study also found that women with false‐positive results did not blame medical technology or lose confidence in screening but continued to desire participation despite their negative experiences.…”

“…An American study shows that 74.1% of American women older than 74 years undergo breast cancer screening despite the US Preventive Task Force recommendation not to. 25 Previous work addressing the communication of discontinuing mammography screening supported that women feel devalued when discontinued from screening, 23 , 51 , 52 and perceived inviting older women to screen as a symbol that society still cares about them. 31 The participants in our study intuitively assumed that age‐related discontinuation from screening was a case of ageism.…”

“…However, most older women are resistant to discontinuing breast cancer screening despite severe health conditions, short life expectancy, information about harm, and physician's recommendation not to be screened. 21 , 22 , 23 , 24 A survey quantified the prevalence of overscreening and showed that about half of older American adults reported being screened for cancer beyond the upper age limit recommended by the US Preventive Task Force. 25 This magnitude of overscreening might be explained by the fact that women generally have high expectations of mammography screening, overestimate benefits, and feel reassured of their well‐being from participation.…”

Breast Cancer Awareness and Association with Frequency of Screening Among Women — China, 2020

“…In this investigation, we employed a modified definition of BCAM that does not include older age as a non-modifiable factor, which consequently led to more challenging questions and decreased levels of awareness. This decision was made based on the observation that peak breast cancer incidence in Chinese women occurs around menopause, rather than increasing with age (7). Gaining knowledge of non-modifiable risk factors not only enables women to assess their own risk but also encourages adherence to routine screening and timely diagnosis (8).…”

Predictors of cancer risky and preventive behaviors among the Nebraska farmers population

“…[14][15][16][17] Yet, many people do not receive cancer screening due to lack of awareness, lack of access to health care, and cost. 18,19 In order to fill the knowledge gaps in behavioral risk factors among agricultural producers, the Nebraska Cancer Prevention Survey was explicitly designed to study a wide range of cancer risk and preventive behaviors including cancer screening (cervical, breast, skin, colorectal, and prostate cancers), fruit and vegetable intake, physical activity, tan-…”