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Figure.
Relative Preference of 881 Older Adults Regarding 13 Phrases a Clinician May Use to Explain Stopping Routine Cancer Screening
Relative Preference of 881 Older Adults Regarding 13 Phrases a Clinician May Use to Explain Stopping Routine Cancer Screening

Standardized scores indicating the strength of preference range from −1.0 (worst) to 1.0 (best). Surveys asked about colorectal, breast, or prostate cancer screening, with questions differing only in the name of the test. The term colonoscopy was used in surveys that asked about colorectal cancer screening; mammogram, in surveys that asked about breast cancer screening; and prostate-specific antigen (PSA), in surveys that asked about prostate cancer screening.

Table.  
Characteristics of 881 Study Participantsa
Characteristics of 881 Study Participantsa
1.
Harris  RP, Wilt  TJ, Qaseem  A; High Value Care Task Force of the American College of Physicians.  A value framework for cancer screening: advice for high-value care from the American College of Physicians.  Ann Intern Med. 2015;162(10):712-717. doi:10.7326/M14-2327PubMedGoogle ScholarCrossref
2.
Kotwal  AA, Schonberg  MA.  Cancer screening in the elderly: a review of breast, colorectal, lung, and prostate cancer screening.  Cancer J. 2017;23(4):246-253. doi:10.1097/PPO.0000000000000274PubMedGoogle Scholar
3.
Royce  TJ, Hendrix  LH, Stokes  WA, Allen  IM, Chen  RC.  Cancer screening rates in individuals with different life expectancies.  JAMA Intern Med. 2014;174(10):1558-1565. doi:10.1001/jamainternmed.2014.3895PubMedGoogle ScholarCrossref
4.
Flynn  TN, Louviere  JJ, Peters  TJ, Coast  J.  Best-worst scaling: what it can do for health care research and how to do it.  J Health Econ. 2007;26(1):171-189. doi:10.1016/j.jhealeco.2006.04.002PubMedGoogle ScholarCrossref
5.
Schoenborn  NL, Lee  K, Pollack  CE,  et al.  Older adults’ views and communication preferences about cancer screening cessation.  JAMA Intern Med. 2017;177(8):1121-1128. doi:10.1001/jamainternmed.2017.1778PubMedGoogle ScholarCrossref
6.
Schoenborn  NL, Bowman  TL  II, Cayea  D, Boyd  C, Feeser  S, Pollack  CE.  Discussion strategies that primary care clinicians use when stopping cancer screening in older adults.  J Am Geriatr Soc. 2016;64(11):e221-e223. doi:10.1111/jgs.14444PubMedGoogle ScholarCrossref
Research Letter
August 2018

Preferred Clinician Communication About Stopping Cancer Screening Among Older US Adults: Results From a National Survey

Author Affiliations
  • 1Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 2Department of Health Policy and Management, The Johns Hopkins University School of Public Health, Baltimore, Maryland
  • 3Currently with ICON Plc, Gaithersburg, Maryland
  • 4Currently with Department of Biomedical Informatics, The Ohio State University, Columbus
  • 5Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
JAMA Oncol. 2018;4(8):1126-1128. doi:10.1001/jamaoncol.2018.2100

Clinical practice guidelines recommend against routine cancer screening in older adults in whom the potential harms of screening outweigh the benefits, which are often defined by specific age or life expectancy thresholds.1,2 However, many older adults who meet these thresholds for stopping routine screening continue to undergo screening for breast, prostate, and colorectal cancers.3 One contributor to this discrepancy may be that clinicians are uncomfortable discussing cancer screening cessation. This project aimed to identify older adults’ preferred communication strategies for clinicians to use when discussing stopping cancer screening.

Methods

We conducted a cross-sectional survey using a probability-based online panel (KnowledgePanel) representative of US adults. KnowledgePanel is a product of GfK, a survey research firm, and panel members are recruited by random digit dialing and address-based sampling. Among 1272 eligible panel members (aged ≥65 years, English-speaking) invited to participate, 881 (69.3%) completed the survey in November 2016. We used the best-worst scaling method to test the participants’ preferences for 13 different phrases that a clinician may use to explain why a patient should not undergo a routine cancer screening test.4 The phrases were identified from previous qualitative interviews with older adults and primary care physicians5,6 and literature review (Figure). Participants were randomized to questions about prostate or breast cancer screening or colorectal cancer screening. As noted at the beginning of the online survey, completion of the survey served as consent to participate in the research study. This project was approved by a Johns Hopkins School of Medicine Institutional Review Board.

Best-worst scaling is a stated-preference research method that allows relative preferences to be quantified and compared across objects, which is not possible with traditional Likert scales.4 We constructed 13 choice tasks, each displaying 4 of the 13 phrases, and asked participants to choose 1 best phrase and 1 worst phrase in each choice task. A standardized score was calculated for each phrase by dividing the sum of assigned values (1 each time a phrase was chosen as best, −1 each time chosen as worst) by the number of times the phrase was presented in the survey. The score indicates the relative strength of the preference for a phrase and ranges from −1.0 (least preferred) to 1.0 (most preferred). Survey weights were applied to adjust for nonresponse and oversampling of African Americans. All statistical analyses were performed using Stata version 13 (StataCorp).

Results

The mean (SD) age of the 881 participants was 73.4 (6.1) years, and 464 (55.2%) were female. Five hundred seventy-six participants (77.2%) were white, non-Hispanic; 216 (8.8%) were African American, non-Hispanic; 47 (8.2%) were Hispanic; and 42 (5.8%) were of another race/ethnicity. Six hundred thirty-one participants (66.0%) had undergone a mammogram or prostate-specific antigen test within the preceding 2 years or a colonoscopy within the preceding 10 years (Table). The most preferred phrase to explain stopping cancer screening was “your other health issues should take priority” (mean score, 0.41; 95% CI, 0.39-0.43), and the least preferred option was “the doctor does not give an explanation” (score, −0.42; 95% CI, −0.44 to −0.40) (Figure). Other more preferred phrases included references to guidelines, older age, the lack of benefit, and the high risk for harm from the screening test. Less preferred were phrases that mentioned life expectancy, the discomfort or inconvenience of the screening test, and the clinician not bringing up a discussion of cancer screening. Separate analyses by cancer screening type found minimal differences in the preference rankings or the standardized scores of the phrases across cancer screening types.

Discussion

This is the first study, to our knowledge, to characterize and quantify older adults’ preferences for how clinicians can discuss stopping breast, prostate, and colorectal cancer screenings. Although the study relied on a hypothetical scenario, this approach allowed us to elicit perspectives from a large national sample. Consistent with results from an earlier qualitative study,5 we found that the most preferred explanation centered on a priority shift to focus on other health issues. Explanations that mentioned guidelines and that mentioned older age were also highly rated, whereas mentioning life expectancy ranked low. Clinical practice guidelines increasingly advocate using life expectancy to inform cancer screening recommendations,1,2 and our findings highlight the importance of communicating these guidelines in language that is acceptable to and preferred by patients. In particular, framing the discussion around lack of benefit, without necessarily mentioning life expectancy, may be a more appealing communication strategy. Simply omitting discussion about cancer screening as a way to stop screening was not a preferred approach, which raises an ethical dilemma about whether an opportunity to discuss stopping cancer screening should at least be offered by clinicians.

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Article Information

Accepted for Publication: April 9, 2018.

Corresponding Author: Nancy L. Schoenborn, MD, MHS, Department of Medicine, The Johns Hopkins University School of Medicine, 5200 Eastern Ave, Mason F. Lord Building Center Tower, Room 711, Baltimore, MD 21224 (nancyli@jhmi.edu).

Published Online: June 28, 2018. doi:10.1001/jamaoncol.2018.2100

Author Contributions: Dr Schoenborn had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Schoenborn, Boyd, Bridges, Pollack

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Schoenborn, Janssen.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Schoenborn, Janssen.

Obtained funding: Schoenborn, Bridges.

Administrative, technical, or material support: Schoenborn, Bridges.

Supervision: Boyd, Bridges, Pollack.

Conflict of Interest Disclosures: Dr Pollack reported owning stock in Gilead Sciences, Inc. No other disclosures were reported.

Funding/Support: This research was supported by grant R03AG050912 from the National Institute on Aging of the National Institutes of Health (NIH). In addition, Dr Schoenborn was supported by a T. Franklin Williams Scholarship Award (funded by Atlantic Philanthropies, Inc, the John A. Hartford Foundation, the Alliance for Academic Internal Medicine–Association of Specialty Professors, and the American Geriatrics Society), the Johns Hopkins KL2 Clinical Scholars program (funded by grant KL2TR001077 from the National Center for Advancing Translational Sciences of the NIH and NIH Roadmap for Medical Research), and Cancer Control Career Development Award CCCDA-16-002-01 from the American Cancer Society. Dr Boyd was supported by grant 1K24AG056578 from the National Institute on Aging.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Meeting Presentations: An earlier version of this manuscript was presented as an oral abstract at the Fifth International Conference on Preventing Overdiagnosis; August 18, 2017; Quebec City, Quebec, Canada; the 2018 Society of General Internal Medicine annual meeting; April 14, 2018; Denver, Colorado; and the 2018 American Geriatrics Society meeting; May 4, 2018; Orlando, Florida.

References
1.
Harris  RP, Wilt  TJ, Qaseem  A; High Value Care Task Force of the American College of Physicians.  A value framework for cancer screening: advice for high-value care from the American College of Physicians.  Ann Intern Med. 2015;162(10):712-717. doi:10.7326/M14-2327PubMedGoogle ScholarCrossref
2.
Kotwal  AA, Schonberg  MA.  Cancer screening in the elderly: a review of breast, colorectal, lung, and prostate cancer screening.  Cancer J. 2017;23(4):246-253. doi:10.1097/PPO.0000000000000274PubMedGoogle Scholar
3.
Royce  TJ, Hendrix  LH, Stokes  WA, Allen  IM, Chen  RC.  Cancer screening rates in individuals with different life expectancies.  JAMA Intern Med. 2014;174(10):1558-1565. doi:10.1001/jamainternmed.2014.3895PubMedGoogle ScholarCrossref
4.
Flynn  TN, Louviere  JJ, Peters  TJ, Coast  J.  Best-worst scaling: what it can do for health care research and how to do it.  J Health Econ. 2007;26(1):171-189. doi:10.1016/j.jhealeco.2006.04.002PubMedGoogle ScholarCrossref
5.
Schoenborn  NL, Lee  K, Pollack  CE,  et al.  Older adults’ views and communication preferences about cancer screening cessation.  JAMA Intern Med. 2017;177(8):1121-1128. doi:10.1001/jamainternmed.2017.1778PubMedGoogle ScholarCrossref
6.
Schoenborn  NL, Bowman  TL  II, Cayea  D, Boyd  C, Feeser  S, Pollack  CE.  Discussion strategies that primary care clinicians use when stopping cancer screening in older adults.  J Am Geriatr Soc. 2016;64(11):e221-e223. doi:10.1111/jgs.14444PubMedGoogle ScholarCrossref
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