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Older Adults' Cancer Screening Intentions and Recalled Are We Choosing Wisely? Older Adults’ Cancer Screening Intentions and Recalled Discussions with Physicians About Stopping Ashwin A. Kotwal, MD, MS1,2,LouiseC.Walter,MD1,2, Sei J. Lee, MD, MAS1,2,and William Dale, MD, PhD3 1Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; 2Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA; 3Department of Supportive Care Medicine, City of Hope National Medical Center, Duarte, CA, USA. BACKGROUND: National guidelines recommend against necessary may be a modifiable risk factor for reducing cancer screening for older individuals with less than a 10- overscreening in older adults with limited life expectancy. year life expectancy, but it is unknown if this population KEY WORDS: desires ongoing screening. cancer screening; aging; patient-centered care. OBJECTIVE: To determine (1) if older individuals with < J Gen Intern Med 34(8):1538–45 10-year life expectancy have future intentions for cancer DOI: 10.1007/s11606-019-05064-w screening, (2) if they recall a doctor previously suggesting © Society of General Internal Medicine 2019 that screening is no longer needed, and (3) individual characteristics associated with intentions to seek screening. DESIGN: National Social life Health and Aging Project INTRODUCTION (2015–2016), a nationally representative, cross-sectional survey. Cancer screening remains a standard aspect of preventive med- PARTICIPANTS: Community-dwelling adults 55– ical care. However, it is increasingly recognized that the priority 97 years old (n = 3816). of engaging in certain preventive medical interventions should MAIN MEASURES: Self-reported: (1) mammography and change as individuals get older or life expectancy becomes PSA testing within the last 2 years, (2) future intentions to limited. For cancer screening, studies indicate there is a signifi- be screened, and (3) discussion with a doctor that screen- cant lag time to benefit; for breast cancer screening, it is approx- ing is no longer needed. Ten-year life expectancy was imately 10 years,1 and for prostate cancer screening likely longer estimated using the Lee prognostic index. Multivariate 2 logistic regression analysis examined intentions to pur- than 10 years. Consequently, those with < 10 years of estimated sue future screening, adjusting for sociodemographic and life expectancy are unlikely to have lower cancer-specific mor- health covariates. tality due to screening.3 Meanwhile, older, frail, and/or cogni- KEY RESULTS: Among women 75–84 with < 10-year life tively impaired adults are at greater risk for immediate potential expectancy, 59% intend on future mammography and harms of screening and follow-up procedures.4 As a result, 81% recall no conversation with a doctor that mammog- professional organizations and guidelines, such as the Choosing raphy may no longer be necessary. Among men 75–84 with < 10-year life expectancy, 54% intend on future PSA Wisely campaign, recommend against cancer screening for those screening and 77% recall no discussions that PSA screen- who are older (generally > 75 years old), with less than a 10-year ing may be unnecessary. In adjusted analyses, those life expectancy, and for whom the potential for adverse events, – reporting recent cancer screening or no recollection that overdiagnosis, and overtreatment are high.5 10 screening may not be necessary were more likely to want Despite national guidelines, rates of cancer screening future mammography or PSA screening (p <0.001). among older adults with limited life expectancy remain high. CONCLUSION: Over 75% of older individuals with limited A study utilizing nationally representative NHIS 2008 and life expectancy intend to continue cancer screening, and 2010 data, for example, found that 36% of women with < 5- less than 25% recall discussing with physicians the need for these tests. In addition to public health and education year life expectancy and 56% of women > 75 years old re- 11 efforts, these results suggest that older adults’ recollec- ported a screening mammogram in the past 2 years. Simi- tion of being told by physicians that screening is not larly for prostate cancer screening with prostate-specific anti- gen (PSA) tests, 30–50% of men with < 10-year life expec- 12–14 Electronic supplementary material The online version of this article tancy had recent PSA tests, and these rates declined only (https://doi.org/10.1007/s11606-019-05064-w)containssupplementary slightly following changes to national guidelines.15 High rates material, which is available to authorized users. of overscreening likely reflect enthusiasm for what is viewed Received August 1, 2018 as a positive health behavior,16 overestimation of the benefits, Revised January 11, 2019 Accepted April 11, 2019 low awareness of the potential harms, and a reluctance to 17–19 Published online May 30, 2019 stop. In addition, physicians often have time limitations 1538 JGIM Kotwal et al.: Future Cancer Screening Intentions in Older Adults 1539 preventing and/or general discomfort in having discussions behavior related to PSA tests and mammograms using three related to stopping screening and in accurately estimating life questions. First, we ask BDo you plan to have regular mam- expectancy.20 mograms or PSA tests in the future?^ with responses of BYes,^ Gaps remain in our understanding of patient- and provider- BNo,^ or if volunteered BIdowhatmydoctorsays.^ This related contributors to continuing cancer screening despite variable is used as the primary outcome in regression analysis. limited life expectancy. Studies examining adults’ enthusiasm Second, we ask BHow long has it been since you had a for cancer screening generally focus on younger individuals mammogram or PSA test?^ Responses within a 2-year inter- and do not include measures of life expectancy or large sam- val represented a Brecent screen^ based on national guide- ples of older adults.16 An assessment of whether older adults, lines.6,7,9 Prior studies suggest reasonable accuracy of self- especially those with limited estimated life expectancies, have reported screening as compared to medical records for both future intentions for undergoing screening is needed as it could mammograms and PSA tests.23,24 Third, we ask BHas a doctor guide physician communication strategies for shared decision- ever suggested you may no longer need regular mammograms making. In addition, it is unclear how many adults, for whom or PSA tests?^ with responses of BYes^ or BNo.^ cancer screening is not recommended, are even aware that there exist recommendations to avoid these tests or recall Life Expectancy having a discussion with their doctors. The Lee prognostic index includes 12 items that together Therefore, we used nationally representative 2015–2016 predict 5- and 10-year life expectancy.25,26 We constructed a data from the National Social life Health and Aging Project slightly modified version of the Lee prognostic index utilizing (NSHAP) to determine (1) if older adults with limited life available items from NSHAP. The following 10 items were expectancies have future intentions to pursue screening, (2) included directly from NSHAP: (1) Age (ages 60–64, 1 point; if they recall a doctor previously suggesting that screening is 65–69, 2 points; 70–74, 3 points; 75–79, 4 points; 80–84, 5 no longer needed, and (3) individual characteristics indepen- points; > 84, 7 points); (2) male sex (2 points); (3) current dently associated with older adults’ future intentions to seek tobacco use (2 points); (4) body mass index < 25 (1 point); (5) screening. diabetes (1 point); (6) non-skin cancers (2 points); (7) chronic lung disease (2 points); (8) heart failure (2 points); (9) diffi- culty bathing (2 points); and (10) difficulty managing finances METHODS (2 points). The following two items in the original Lee index were substituted with available items from NSHAP: (1) Study Sample Bdifficulty walking several blocks^ was substituted with the We used the National Social Life Health and Aging Project, NSHAP item Bdifficulty walking one block^ (2 points); (2) Wave 3 sample (NSHAP-W3), a US nationally representative Bdifficulty pushing/pulling large objects^ was substituted with probability sample of 4776 older adults. Surveys were con- the NSHAP item Bdifficulty performing housework^ (1 point). ducted face-to-face with Computer Assisted Personal We compared the performance of the original Lee index in Interviewing (CAPI) between September 2015 and September predicting 4-year mortality to the modified Lee index in 2016. NSHAP-W3 included community-dwelling adults > predicting 5-year mortality in NSHAP and found consistent 57 years, and as a sampling strategy, included co-resident performance (Table 1). The range of the modified Lee index is spouses and partners of any age. Individuals unable to com- 0–26 points, and we used cutoff scores of 8+ points and 12+ plete the interview due to physical or cognitive limitations points corresponding to a < 10-year life expectancy and < 5- were not enrolled. Details on the sampling design, recruitment, and inclusion criteria are published elsewhere and available Table 1 Validation of the Modified Lee Prognostic Index for Use in online.21,22 We made the following exclusions for the analysis: NSHAP Compared with the Original Lee Prognostic Index in HRS individuals younger than 55 years old (n = 788) or with prior Points Original Lee index, Modified Lee index in histories of
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