Older Patients Prefer to Base Cancer Screening Decisions on Health Status, Not Life Expectancy

Guidelines recommend against screening for cancer in patients with shortened life expectancy, but a recent study revealed older patients may not want to consider their life expectancy when discussing with a clinician whether they should stop undergoing cancer screening.

According to the research, published in JAMA Internal Medicine, value-based recommendations have identified cancer screening in patients with limited life expectancy as a target for reduction, as it offers minimal benefits but puts patients at risk of harm and is not a cost-effective use of healthcare resources. Despite the advice of guidelines, like the Choosing Wisely recommendations that discourage routine screening in those unlikely to live another 10 years, prior research has estimated that the screening rate remains as high as 55%.

Previous studies have indicated that older adults generally do not consider their life expectancy an important factor in the decision to stop cancer screening, but no research has addressed how patients would prefer to have this conversation with their clinician. The current study set out to gather older adults’ perspectives on the cancer screening cessation decision and learn more about their communication preferences by interviewing community-dwelling patients aged 65 and older.

The study sample included 40 such adults who were recruited from both ambulatory clinics and home-based programs, in order to assess opinions among patients with varying health statuses, functional abilities, and life expectancies. Participants provided demographic characteristics and health histories, and they answered questions so the researchers could assess their health literacy and trust in their clinician.

As part of the interview protocol, researchers first gave a general summary of the possible benefits and harms of cancer screening procedures like mammograms, prostate exams, and colonoscopies. They “explicitly mentioned that it may take up to 10 years before a cancer grows to the point of causing health problems, so that someone who will not live 10 years may not benefit and may be harmed from screening.”

Next, the researchers explored patients’ preferences related to decision-making and communication by asking questions about their views and considerations on cancer screening cessation, as well as their reactions to screening cessation recommendations presented in various communication styles.

The older adults in the study were generally open to the idea of stopping cancer screening. Many reported they would be receptive if their regular physician recommended they stop screening, citing high levels of trust in their clinicians’ judgment. Participants mostly agreed that screening decisions should be made in the context of health status, but all except 2 objected to the idea of making screening decisions based on life expectancy.

These themes were reflected in the participants’ communication preferences. The approach chosen most often was to mention the patient’s health and functional status when discussing cancer screening cessation, but participants differed in their opinions on whether clinicians should mention life expectancy in this conversation.

The study authors noted that these results contradicted previous findings that older patients generally want to continue screening despite recommendations, and wrote that this difference “may stem from the fact that our study participants had high levels of trust and long relationships with their clinicians.”

They also acknowledged that the participants’ aversion to using life expectancy as a factor in screening cessation could be incorporated into clinical guidelines that consider the language preferred by patients.

“Testing these communication preferences in larger populations to better delineate patient-centered approaches to discuss screening cessation is an important step toward optimizing cancer screening in older adults,” the researchers concluded.