“Introduction
Although cancer screening has been shown to reduce cancer-related mortality and morbidity, there is increasing recognition that it can also be harmful and burdensome, especially for older adults. The benefits of cancer screening typically lag by 10 or more years for breast, colorectal, and prostate cancer screenings, whereas the harms and burdens of these screenings—which include complications from screening and follow-up tests, overdiagnosis and overtreatment of clinically unimportant cancers, psychological stress from false-positive results, diverted attention away from other health conditions—occur in the short term. Guidelines recommend against routine cancer screening for older adults for whom the harms outweigh the benefits, using age or life expectancy criteria. However, national studies show that many older adults who meet guideline criteria for cancer screening cessation continue to be screened for breast, colorectal, and prostate cancers, raising concerns for overscreening. [..]
Methods
In a national cross-sectional survey, we assessed physician decision-making about cessation of screening for breast, colorectal, and prostate cancers for adults 65 years or older. We used the American Medical Association (AMA) Physician Masterfile, which contains information on all US practicing physicians, not only AMA members. We obtained a random sample of 1800 physicians in internal medicine, family medicine, general practice, and geriatric medicine (hereafter, primary care physicians) and 600 gynecologists because some women receive breast cancer screening through their gynecologist rather than their primary care physician. Primary care physicians were randomized to receive 1 of 3 survey versions on breast, colorectal, or prostate cancer screenings. Gynecologists were surveyed only about breast cancer screening. [..]
We mailed the surveys, with 2 follow-up mailings to nonresponders, between April 29 and November 8, 2021. An unconditional $20 incentive was included in the first mailing. A $40 gift card was offered on survey completion in the last mailing. Physicians could respond to the paper-based survey or online. Follow-up telephone calls were made to nonresponders. [..]
Results
Among the 993 responders, we excluded 134 who reported not caring for any older adults, 40 who reported not practicing in the outpatient setting, and 43 who did not respond to the primary outcome question for at least 1 patient vignette or chose more than 1 response for the primary outcome, leaving 776 participants (mean age, 51.4 years [range, 27-91 years]; 402 of 775 participants were men [51.9%]; 508 of 746 participants were White [68.1%]) in the analytical sample. The most common specialty represented was family medicine or general practice (316 [40.7%]), followed by internal medicine (255 [32.9%]) and gynecology (190 [24.5%]).
Across the 2 patient vignettes, description of the patient’s health conditions and functional status was most often chosen by the participants (in 36.7% of vignettes [569 of 1552]) as the most influential factor associated with cessation of screening, followed by cancer risk in the patient’s remaining lifetime (34.9% of vignettes [542 of 1552]); life expectancy was chosen in 23.1% of vignettes (358 of 1552) as the most influential factor, while physiological age was chosen in only 5.3% of vignettes (83 of 1552) as the most influential factor. [..]
Discussion
[..] Description of the patient’s health conditions and functional status was most often chosen by physicians as the most influential information when deciding about cessation of cancer screening. This is the type of information that physicians are most likely to be already familiar with about the patients. [..]
In contrast, a patient’s risk of dying from cancer in the remainder of their lifetime is not information that is readily available to physicians, yet this was perceived more than one-third of the time by physicians to be the most influential information when considering cancer screening cessation. A patient’s risk of dying from a specific cancer in the remainder of their lifetime is estimated by using life expectancy and population-level cancer mortality data. Guidelines increasingly recommend against routine screening for patients with limited life expectancy, but both physicians and older adults have reported skepticism about using life expectancy to guide cancer screening decisions. Reframing the discussion from limited life expectancy to low cancer risk in the patient’s remaining lifetime in clinical practice guidelines may be one way to enhance acceptability and adherence. For clinicians to use this information, however, it would likely require the implementation of decision support tools at the point of care that can present and emphasize a patient’s low risk of dying from a cancer in their remaining lifetime. One advantage of this framework of applying life expectancy to estimate individualized cancer risk is that it can be extended to other preventive care decisions, such as the risk of a cardiovascular event in a patient’s remaining lifetime when deciding about statin therapy. [..]
Our finding suggests that physicians also consider life expectancy more relevant as life expectancy becomes more limited. This may be because trust in the accuracy of estimating life expectancy is higher when estimating over a shorter time horizon. It also may be that it is more straightforward to base decision-making on life expectancy when life expectancy is clearly shorter than the guideline threshold as opposed to when life expectancy is close to the threshold. [..]
Physicians chose physiological age as the most influential factor in screening decisions only 5.3% of the time. Physiological age is a common topic of study in published scientific literature. Multiple studies have developed various tools to estimate physiological age, while others emphasize its influence in myriad decisions ranging from cardiovascular treatment to transplant surgery. Specifically, physiological age has been used to inform individualized cancer screening recommendations for older adults. Our results suggest that practicing physicians may be unfamiliar with the term or concept of physiological age, or they may perceive it as less relevant in screening cessation decisions. Future work may seek to better understand physicians’ perceptions and understanding of physiological age and how it may influence decision-making. [..]
Conclusions
There are multiple ways to present patient health information; this survey study found that physicians often perceived information about the risk of dying from cancer in the patient’s remaining lifetime or life expectancy as influential factors when making decisions about cancer screening cessation for older adults. Making such information readily accessible at the point of care may help reduce overscreening.”
Full article, NL Schoenborn, CM Boyd and CE Pollack, JAMA Network Open, 2023.5.15