There are many educational efforts designed to increase the rates of screening for cancer, which is an important part of standard medical care. However, the balance of the risks and benefits of screening are affected by situations such as comorbid illness, poor functional status, or advanced age. Screening tests with positive results lead to a variety of diagnostic and treatment interventions that carry risk; the risk may be intensified in older adults with dementia, whose condition make compliance with testing and treatment regimens more difficult.
There have been studies showing an increased rate of cancer screening in patients who are not likely to benefit due to advanced age or serious illness. Results from these studies have led to changes in recommendations for screening in populations where such testing is nonbeneficial or potentially harmful. The US Preventive Services Task Force has begun to issue recommendations for stopping points based on age for some screening, including stopping screening for colon cancer at 75 years of age and cervical cancer at 65 years of age. Other organizations, including the American Geriatrics Society, recommend an individualized approach for clinicians making screening decisions for older adults.
According to researchers, little is known about patients’ perceptions about stopping cancer screening. In an effort to help both clinicians and those designing interventions to reduce overscreening, the researchers conducted a study to obtain an understanding of older adults’ perspectives on screening cessation and their experience communicating with their physicians on this topic. The researchers reported results of the semistructured interview study online in JAMA Internal Medicine [doi:10.1001/jamainternmed.2013.2903].
The study setting was a senior health center affiliated with an urban public hospital. Potential participants were ≥60 years of age who attended regularly scheduled primary care or specialty memory disorder clinic visits. The primary outcome measures of the study cited by the researchers were analyses of transcribed audio recordings of interviews using methods of grounded theory to identify themes and illustrative quotes.
After applying inclusion and exclusion criteria, the researchers enrolled 33 patients in the study. Median age was 76 years (range, 63-91 years), 27 were women, 17 were white, 17 were African American, 1 was Asian, and 1 was American Indian. Study interviews were a mean of 25 minutes (range, 13-40 minutes).
The researchers found that patients had highly favorable views of screening, reflected in many reasons to screen that were expressed by the study participants. Overriding these positive views of screening was the sense that screening was a moral obligation and was equated directly with health and life. Few participants had discussed screening cessation with a physician.
Participants mentioned things that might influence a decision to stop screening, such as poor health or the burden on others. They also said that if their physician suggested stopping screening, they would question the recommendation or seek a second opinion.
When asked about recommendations for screening cessation offered by experts or government panels, the responses were generally negative. A common reaction was a lack of faith in the seemingly ever-changing guidelines offered; others raised concerns about government recommendations against screening being based on financial incentives.
The participants had more favorable reactions to stopping screening based on the burdens of the test or if the burdens outweighed the benefits. Colonoscopy was commonly cited as an example of a burdensome procedure.
In conclusion, the researchers said, “For many older adults, stopping screening is a major decision, but continuing screening is not. A physician’s recommendation to stop may threaten patient trust. Effective strategies to reduce nonbeneficial screening may include discussion of the balance of risks and benefits, complications, or burdens.”