Patient-Reported Factors Associated With Older Adults' Cancer Screening Decision-making: A Systematic Review
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
- 2Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
Objective of the study:
To summarize the patient-reported factors associated with older adults' decisions regarding screening for breast, prostate, colorectal, and cervical cancer.
21 studies were included.
Factors associated with decision-making were synthesized into 5 categories: demographic, health and clinical, psychological, physician, and social system.
The most commonly identified factors included personal or family history of cancer, positive screening attitudes, routine or habit, gaining knowledge, friends, and a physician’s recommendation.
Although 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.
Consequently, 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.
Cancer Rose commentary
We analyzed the CNGOF (CNGOF-French national college of obstetricians and gynecologists) campaign of 2019, a stunning "cry of alarm" for breast cancer screening in older women, with spectacular media coverage in a clear sky, while no country practicing screening recommends screening beyond the age of 74, nor even the WHO...
Why is this campaign, still relayed on this learned society's homepage, a danger to the elderly?
A study from the University of Leyden provides an answer.
Few trials have focused on screening women in old age. The study by researchers from the University of Leyden on data from the Netherlands, published in 2014 in the BMJ, makes up for this lack.
According to the authors, after the age of 70, organized breast cancer screening would be useless. Indeed, at this age, screening does not significantly improve the detection of advanced cancers but instead increases the number of overdiagnosis and, therefore, overtreatment.
In the Netherlands, breast cancer screening has been offered to women up to 75 since the late 1990s. "Yet there is no evidence that screening older women is effective," the study authors explain, citing that few trials have been conducted specifically on these age groups.
For the Dutch researchers, systematic screening after 70 years of age would mainly lead to the detection and treatment of lesions that would not have developed into disease during the life of the patients.
These unnecessary treatments have a considerable impact on health, and the co-morbidity of these older adults is too high, as they are less able to tolerate the side effects of treatments, such as surgery, radiotherapy, and chemotherapy.
For this reason, they recommend that generalized screening not be extended to those over 70 years of age and recommend an individualized decision based on life expectancy, breast cancer risk, general condition, and preference of the women concerned.
It should also be remembered that the immune system weakens with age. This means that we contract more cancers and infectious diseases. All the organs become exhausted and function less well, and the healing and tissue regeneration faculties are lessened, all of which must be considered when administering heavy treatments.
A point of view published in the JAMA in 2019 raised the question of the relevance of screening for older adults. While all recommendations stop this screening at 74 years of age, it is unfortunately not uncommon to see people beyond that age being sent for screening and "check-ups."
The authors argue that the evidence of benefits for older adults is unclear, and the chance of harm becomes greater (e.g., overdiagnosis, burdens of additional testing, false-positive results, and psychological impacts).
Although aging-related concepts are challenging to communicate, older people must be counseled about the reduced benefit and increased chance of harm from screening associated with limited life expectancy and worsening health to make better quality screening decisions. Communication strategies are needed that support older adults in making informed cancer screening decisions.
The principle of non-maleficence implies not harming people, a principle that even a learned society like the CNGOF must adopt.
The Australian author reported at this week's ICCH2022 INTERNATIONAL CONFERENCE ON
COMMUNICATION IN HEALTHCARE (September 5-9, 2022, Glasgow), the results of an interview-based study involving general practitioners regarding cancer screening in older adults.
General Practitioners' Approaches to Cancer Screening in Older People, A Qualitative Interview Study
Background: Older adults continue to be screened for cancer with limited knowledge of the potential hams. In Australia, general practitioners (GPs) may play an important role in communication and decision-making around cancer screening for older people. This study aimed to investigate GP’s attitudes and behaviours regarding cancer screening (breast, cervical, prostate and bowel) in patients aged ≥70 years (as screening programs recently began targeting ages 70-74). Methods: Semi-structured interviews were conducted with GPs practising in Australia (n=28), recruited through multiple avenues to ensure diverse perspectives (e.g., practice-based research networks, primary health networks, social media, cold emailing). Transcribed audio-recordings were analysed thematically. Findings: Some GPs initiated screening discussions only with patients younger than the upper targeted age of screening programs (i.e., some thought 69 or 74 years). Others initiated discussions beyond recommended ages. When providing information, some GPs were uncomfortable discussing why screening reminders stop, some believed patients would need to pay to access breast screening, and detailed benefit and harms discussions were more likely for prostate screening. When navigating patient preferences, GPs described patients who were open to recommendation, insistent on continuing/stopping, or offended they were not invited anymore, and tailored their responses accordingly. Ultimately the patient had the final say. Finally, GPs considered the patient’s overall health/function, risk, and previous screening experience as factors in whether screening was worthwhile in older age.
Discussion: There is no uniform approach to cancer screening communication and decision-making for older adults in general practice and limited understanding among both older people and GPs around why screening has an upper targeted age. Tools to support effective communication of the reduced benefit and increased chance of harm from cancer screening in older age are needed to support both older people and GPs to make more informed cancer screening choices.