Discussing Stopping Cancer Screening and Prognosis With Older Adults

Guidelines recommend not screening adults with <10-year life expectancy for cancer; however, primary care physicians feel uncomfortable talking to older adults about prognosis. The investigators aim to determine whether providing PCPs with scripts on patient prognosis and older adults with information on their prognosis would be useful when recommending stopping cancer screening.

Study Overview

• Status: Completed
• Conditions: Cancer Screening
• Intervention / Treatment: Other: Prognosis information and Provider Scripts

Detailed Description

The American Cancer Society and the American Board of Internal Medicine Choosing Wisely Campaign recommend clinicians not screen older adults who have <10 year life expectancy for breast (specific to women) or colorectal cancer (CRC). This is because these patients have little chance of experiencing the life prolonging benefits of cancer screening and instead may only experience harm from being screened. The most concerning harm of cancer screening is overdiagnosis - the diagnosis and treatment of cancers that otherwise would not have caused problems in an older adult's lifetime. Despite this, around half of adults >75 years with <10 year life expectancy are regularly screened for cancer. One reason for the overuse of these tests is that PCPs feel uncomfortable discussing stopping screening with older adults since it requires estimating and discussing patient prognosis. Some PCPs admit to recommending cancer screening to older adults with short life expectancy simply to avoid talking to patients about prognosis. However, by avoiding these discussions, PCPs may be impeding older adults' ability to make informed decisions about their care and may be putting patients at risk of the harms of cancer screening without any chance of benefit. Therefore, the investigators aim to interview PCPs and older adults about their thoughts and feelings on how PCPs may discuss older adults' prognosis in the context of talking about stopping cancer screening. Based on those findings, the investigators will develop strategies for PCPs to use to approach these discussions and will draft scripts to suggest language for PCPs to use when communicating about prognosis when recommending stopping cancer screening. Then, the investigators will study if providing PCPs with these scripts and information about their patients' prognosis is useful. Specifically, the investigators will provide 45 PCPs with information about their patients' prognosis and the example scripts before a clinic visit for up to 5 of their patients. The investigators aim to recruit 90 patients with approximately 5-10 year life expectancy. The investigators will interview PCPs and older adults after these visits to learn how and/or if the prognostic information and the scripts were used. These data are essential for improving the quality of PCP discussions around stopping cancer screening and will ultimately improve the care of older adults.

Specific Aims:

1. To learn from PCPs and older adults about how to discuss patient prognosis when recommending stopping cancer screening and to develop strategies for having these discussions.
2. To study whether providing information on patient prognosis and scripts for discussing patient prognosis when recommending stopping cancer screening are useful to PCPs and older adults.

• Study Type: Interventional
• Enrollment (Actual): 90
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Massachusetts
    • Boston, Massachusetts, United States, 02215
      • Beth Israel Deaconess Medical Center
    • Boston, Massachusetts, United States, 02215
      • BIDMC Affiliated Physicians Group

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 76 years to 89 years (Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• English-speaking
• Aged 76 to 89 years
• Scheduled for a routine visit or physical with their PCP in the next 3-12 weeks
• Patient aged 76-79 must have a least one Charlson Comorbidity
• Patient must have undergone CRC screening within the last 10 years
• Women only: patient must have undergone mammography screening within the last 3 years

Exclusion Criteria:

• older adults with dementia
• older adults with a history of colon cancer
• older adults whose last colonoscopy was read as abnormal
• older women who have a history of breast cancer
• older adults whose PCP has already had 5 patients participate in the study
• older women whose last mammogram was read as abnormal

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Experimental: Prognosis Information and Provider Scripts; Investigators will send the PCP via secure email the patient's prognosis calculated by the Lee-Schonberg index three days before the patient visit. Investigators will also send PCPs information on patient life expectancy from Cho et al.'s US life tables and scripts developed to sensitively include information on patient prognosis when recommending patients stop being screened for cancer. After five of their patients have participated or recruitment goals are met, investigators will ask PCPs to complete a 10 minute web-based questionnaire about their experience.

Other: Prognosis information and Provider Scripts; An individualized report including each patient's prognosis will be calculated by the Lee-Schonberg and will include information on patient life expectancy from Cho et al.'s US life tables. This report will be sent to the PCP three days before the patient visit. Example scripts for PCPs to use with patients when discussing life expectancy and stopping cancer screening will be sent with the patient prognostic information.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Intentions to be Screened for Colorectal Cancer.	Intentions to be screened was measured in a pretest-survey and again within 2 weeks of a PCP visit using the choice/predisposition scale which is measured from 1-15 on a 15 point scale. A score of 1 means that a person does not intend to be screened. A score of 15 means that the person does intend to be screened. A score of 8 means they are unsure. Scores between 2-7 means the person is leaning towards not being screened. A score of 9-14 means that person is leaning towards being screened. We examined the change in intentions to be screened from pretest to the posttest survey. The mean delta was determined at the time of the post-test survey which was completed within two weeks of the PCP visit.	2 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Discussion of stopping cancer screening and prognosis	The investigators will report how many patients reported that their PCPs discussed stopping cancer screening and/or their prognosis	1 week
Perception of discussions	The investigators will report the patient perceptions of conversations that they had with their PCPs about stopping cancer screening and/or their prognosis	1 week
Prognostic information acceptability	The investigators will report whether PCPs found prognostic information useful and/or helpful [very, somewhat, a little, not at all] after using the intervention.	1 week
PCP Facilitators	The investigators will examine facilitators noted by PCPs when using the prognostic tools and scripts to discuss stopping cancer screening and life expectancy with older adult patients.	1 week
PCP Barriers	The investigators will examine barriers noted by PCPs when using the prognostic tools and scripts to discuss stopping cancer screening and life expectancy with older adult patients.	1 week
Difference in PCP experiences	The investigators will report differences by sex and practice site (BIDMC/APG) of PCPs by using a chi-square test.	Up to 18 months

Collaborators and Investigators

• Sponsor: Beth Israel Deaconess Medical Center
• Collaborators: National Cancer Institute (NCI)
• Investigators: Principal Investigator: Mara A Schonberg, MD, MPH, Beth Israel Deaconess Medical Center

Publications and helpful links

General Publications

• Schonberg MA, Karamourtopoulos M, Jacobson AR, Aliberti GM, Pinheiro A, Smith AK, Davis RB, Schuttner LC, Hamel MB. A Strategy to Prepare Primary Care Clinicians for Discussing Stopping Cancer Screening With Adults Older Than 75 Years. Innov Aging. 2020 Jul 7;4(4):igaa027. doi: 10.1093/geroni/igaa027. eCollection 2020.

Study record dates

Study Major Dates

• Study Start (Actual): October 3, 2017
• Primary Completion (Actual): October 1, 2019
• Study Completion (Actual): October 1, 2021

Study Registration Dates

• First Submitted: March 9, 2018
• First Submitted That Met QC Criteria: March 21, 2018
• First Posted (Actual): March 29, 2018

Study Record Updates

• Last Update Posted (Actual): January 30, 2024
• Last Update Submitted That Met QC Criteria: January 22, 2024
• Last Verified: January 1, 2024

More Information

Terms related to this study

• Keywords: Primary care; Older adults; Cancer screening; Life expectancy
• Other Study ID Numbers: 2016P000244; R21CA212386 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No