Friday, September 20, 2019
3 Questions on… How to Tell Older Adults They've Aged Out of Cancer Screenings
With Nancy Schoenborn, MD, Associate Professor of Geriatric Medicine and Gerontology at Johns Hopkins University School of Medicine
By Sarah DiGiulio
Cancer screenings are indisputably an important aspect of cancer control and cancer care. Early detection of cancers reduces cancer-related mortality and morbidity by allowing problems to be identified earlier when tumors tend to be easier to treat with less-aggressive therapy.
But there's also growing evidence that for some populations more screening is not always better. One such population for whom certain cancer screenings may pose more harms than benefits is older adults, whose life expectancy is shorter than the amount of time it is predicted to take for them to see the benefit of that screening.
"Cancer screening may be associated with a number of short-term harms and burdens in older adults, including complications from screening and follow-up tests, overdiagnosis and overtreatment of clinically unimportant cancers, diverted attention from other health priorities, psychological stress from false-positive results, and increased burden for patients and families," researchers from Johns Hopkins University School of Medicine and UCSF, noted in a study that investigated the subsequent question: how do you tell older patients they've aged out of cancer screenings (Gerontologist 2019;59(Suppl 1):S67-S76)?
The researchers surveyed 28 primary care clinicians and 40 community-dwelling older adults in semi-structured in-person interviews about their views and opinions on communication around stopping cancer screening. The data revealed the following.
- Both groups considered talking about the benefits and risks of cancer screening, and involving the patients as important.
- The clinicians were more likely to be concerned about the patients reacting negatively to talking about stopping cancer screenings, whereas the older adults did not report reacting negatively if the topic was broached in the context of a trusted relationship.
- When it came to specifically talking about a patient's life expectancy in the context of stopping cancer screening, clinicians rarely talked about it and older adults were divided on whether or not they thought it should be discussed.
The study's lead author, Nancy Schoenborn, MD, Associate Professor of Geriatric Medicine and Gerontology at Johns Hopkins University School of Medicine, shared with Oncology Times more about the research and why it's important.
1. Has previous research looked at broaching the topic of stopping cancer screenings with older adults?
"Previous studies have not really looked at the discontinuation of cancer screening, but rather mostly focused on how clinicians and patients consider the decision about continuing cancer screening. Previous studies also have not looked at the communication about discontinuation of cancer screening. We conducted this study because guidelines and research now increasingly recognize that for some patients there are times when cancer screening's harms and burdens outweigh the benefits—and recommend that these patients stop screening. But we know from other studies the practices have not matched up to these recommendations and there are a lot of patients who are overscreened.
"These conversations are difficult because clinicians worry patients would think they are giving up or judgmental if they recommended stopping routine cancer screening. Clinicians also are uncomfortable discussing life expectancy. Research to better understand what messaging frames best resonate with patients can help clinicians make the discussion more patient-centered and acceptable to patients."
2. What were the key findings from this data that you and your colleagues collected?
"Each interview was done one-on-one and lasted 30-60 minutes. With the clinicians, we asked about what factors made them consider stopping cancer screening in a patient, how they approached that discussion, [among others]. With the patients, we asked how they considered the decision to stop cancer screening, how they would react and think of the clinician if that was recommended, and how they would react to different ways of discussing this recommendation.
"We found that older adults can be amenable to stopping routine cancer screening in the context of a trusting relationship, which is reassuring to clinicians—some of whom worried patients may react negatively. We found that there were a range of opinions on whether life expectancy of the patient should be discussed explicitly in this context.
"It was reassuring to find that on the patient side, trust between the clinician and patient really means a lot. Many of the participants would be willing and respond positively to a recommendation to stop cancer screening because they trusted their doctors. It was interesting to find a wide range of preferences among older adults on whether life expectancy should be discussed."
3. So, what's the takeaway from this research?
"Cancer screening is helpful in many people, but sometimes as patients get older and accumulate a number of serious illnesses, there can come a time when the harms and burdens of screening outweigh its benefits and it is appropriate for that patient to consider stopping cancer screening.
"Clinicians and patients should discuss whether this decision is right for each individual patient. Focusing on the balance of benefits and harms may be more preferred than discussing life expectancy for some patients."