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

Abstract

Background: Consideration of older adults' 10-year prognosis is necessary for high-quality cancer screening decisions. However, few primary care providers (PCPs) discuss long-term (10-year) prognosis with older adults.Methods: To learn PCPs' and older adults' perspectives on and to develop strategies for discussing long-term prognosis in the context of cancer screening decisions, we conducted qualitative individual interviews with adults 76-89 and focus groups or individual interviews with PCPs. We recruited participants from 4 community and 2 academic Boston-area practices and completed a thematic analysis of participant responses to open-ended questions on discussing long-term prognosis.Results: Forty-five PCPs (21 community-based) participated in 7 focus groups or 7 individual interviews. Thirty patients participated; 19 (63%) were female, 13 (43%) were non-Hispanic Black, and 13 (43%) were non-Hispanic white.Patients and PCPs had varying views on the utility of discussing long-term prognosis. "For some patients and for some families having this information is really helpful," (PCP participant). Some participants felt that prognostic information could be helpful for future planning, whereas others thought the information could be anxiety-provoking or of "no value" because death is unpredictable; still others were unsure about the value of these discussions. Patients often described thinking about their own prognosis. Yet, PCPs described feeling uncomfortable with these conversations. Patients recommended that discussion of long-term prognosis be anchored to clinical decisions, that information be provided on how this information may be useful, and that patient interest in prognosis be assessed before prognostic information is offered. PCPs recommended that scripts be brief. These recommendations were used to develop example scripts to guide these conversations. Conclusions: We developed scripts and strategies for PCPs to introduce the topic of long-term prognosis with older adults and to provide numerical prognostic information to those interested. Future studies will need to test the effect of these strategies in practice.

Harmful communication behaviors in cancer care: A systematic review of patients and family caregivers perspectives

“…With regard to timing of prognostic information, patients especially perceived harm when prognostic information was discussed too early 25,44,45,55,60–65 . This could cause anxiety and take away hope, which some patients so desperately need to stay upright mentally and physically.…”

“…With regard to timing of prognostic information, patients especially perceived harm when prognostic information was discussed too early. 25,44,45,55,[60][61][62][63][64][65] This could cause anxiety and take away hope, which some patients so desperately need to stay upright mentally and physically. In contrast, caregivers reported that it is harmful when prognostic information is discussed too late (too close to death) 66,67 as it takes away the time to say goodbye to a loved one.…”

“…Starting too late 61,66,67 with discussing the approaching end of life (too close to death) could also cause false hope (for both patient and caregiver). For some, receiving numerical prognostic information was perceived as harmful 22,25,62,63,65,68 because this number is inherently uncertain, but it can get stuck in patients' minds, causing them to suffer mentally (e.g. increase anxiety).…”