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Discussions of Prognosis and Stopping Cancer Screening in Older Adults

老年人预后和停止癌症筛查的讨论

基本信息

批准号：
9386149
负责人：
MARA A SCHONBERG
金额：
$ 23.58万
依托单位：
BETH ISRAEL DEACONESS MEDICAL CENTER
依托单位国家：
美国
项目类别：
财政年份：
2017
资助国家：
美国
起止时间：
2017-07-01 至 2019-06-30
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/9386149
关键词：
Adult Age American American Cancer Society Anxiety Benefits and Risks Breast Cancer Detection Caring Cessation of life Clinic Visits Colon Carcinoma Colorectal Cancer Communication Communities Comorbidity Data Decision Making Detection Diagnosis Elderly Event Expectancy Feeling Focus Groups Goals Guidelines Habits Health Healthcare Individual Internal Medicine Intervention Interview Knowledge Language Learning Life Life Expectancy Life Experience Life Tables Malignant Neoplasms Mammography Medical Methods Modeling Moral Obligations Nurse Practitioners Patients Perception Population Primary Care Physician Primary Health Care Process Provider Public Health Recruitment Activity Reporting Risk Screening for cancer Suggestion System Testing Thinking Time Visit Woman aged base cancer therapy colorectal cancer screening design end of life experience frailty improved mortality older patient outcome forecast preference prevent prognostic programs screening tool tumor

项目摘要

Primary care physicians and nurse practitioners (herein referred to as primary care providers, PCPs) are increasingly being encouraged to take into account older adults' long-term (>5 years) prognosis when deciding whether or not to recommend medical interventions for older adults. One of the most common medical interventions for which PCPs are encouraged to take into account older adults' long-term prognosis is when deciding on cancer screening. It is estimated that 1,000 older adults need to be screened for breast (specific to women only) or colon cancer for one to avoid death from these cancers in 10 years. Due to this 10-year lag- time to benefit, guidelines recommend that adults with <10 year life expectancy not be screened for these cancers. The rationale is that these patients will not live long enough to experience the possible life-prolonging benefits of cancer screening. Instead, screening these patients only puts them at risk of the harms of cancer screening which include: anxiety resulting from false positive tests, overdiagnosis (detection of tumors that are of no threat), and complications from work-up or treatment of cancer. Despite this, many older adults with short life expectancy are screened for cancer. One reason for this is that PCPs avoid talking to older adults about stopping cancer screening. These discussions require consideration and often discussion of patient life expectancy and PCPs report feeling uncomfortable estimating and discussing prognosis with older adults. However, by avoiding these discussions, PCPs may be undermining their patients' ability to make informed decisions around cancer screening and other medical interventions. While there are tools available to help PCPs estimate patient prognosis, there is little information to guide PCPs on how to discuss stopping cancer screening and long-term prognosis with older adults. Therefore, in Aim 1 we plan to conduct focus groups and individual interviews with PCPs (community and academic) and individual interviews with adults 76 to 89 years with 5-10 year life expectancy to learn their thoughts, preferences, and suggestions for how PCPs should approach discussing stopping cancer screening and long-term prognosis with older adults. We will then use these data to develop strategies and guiding principles for PCPs to use for having these discussions and we will create scripts to suggest language for PCPs to use during these discussions. In Aim 2, we will provide 45 PCPs with the drafted scripts and prognostic information for 1-3 of their patients (goal to recruit 90 adults aged 76 to 89 years) before a clinic visit. We will interview PCPs after these visits to learn if the prognostic information was used and whether PCPs found the prognostic information and/or the guiding scripts useful. We will also interview older adults after these visits to learn their perceptions of these conversations and their decision making around cancer screening. There is great need for strategies for PCPs to use to discuss stopping cancer screening and long-term prognosis with older adults so that older adults may make more informed decisions about their care and avoid medical interventions that may only cause them harm.

初级保健医生和执业护士（以下简称初级保健提供者，PCP）是越来越多的人鼓励在做出决定时考虑老年人的长期（> 5 年）预后是否建议对老年人进行医疗干预。最常见的医疗之一鼓励 PCP 考虑老年人长期预后的干预措施是决定癌症筛查。据估计，有 1,000 名老年人需要接受乳房筛查（具体针对仅限女性）或结肠癌，以避免 10 年内死于这些癌症。由于这10年的滞后—— 受益时间，指南建议预期寿命<10年的成年人不要接受这些筛查癌症。理由是这些患者的寿命不足以经历可能的延长生命的过程癌症筛查的好处。相反，对这些患者进行筛查只会使他们面临癌症危害的风险筛查包括：假阳性检测引起的焦虑、过度诊断（检测到不符合预期的肿瘤）没有威胁），以及癌症检查或治疗引起的并发症。尽管如此，许多身材矮小的老年人预期寿命进行癌症筛查。造成这种情况的原因之一是 PCP 避免与老年人谈论停止癌症筛查。这些讨论需要考虑并经常讨论患者的生活预期和 PCP 报告称，与老年人估计和讨论预后感到不舒服。然而，通过回避这些讨论，PCP 可能会削弱患者知情的能力有关癌症筛查和其他医疗干预措施的决定。虽然有一些工具可以提供帮助 PCP 评估患者预后，但指导 PCP 如何讨论阻止癌症的信息很少老年人的筛查和长期预后。因此，在目标 1 中，我们计划开展焦点小组活动，对 PCP（社区和学术界）的个人访谈以及对 76 至 89 岁成年人的个人访谈预期寿命为 5-10 年的人了解他们的想法、偏好以及 PCP 应该如何做的建议方法讨论停止癌症筛查和老年人的长期预后。然后我们将使用这些数据用于制定 PCP 进行这些讨论的策略和指导原则，我们将创建脚本来建议 PCP 在这些讨论期间使用的语言。在目标 2 中，我们将提供 45 PCP 为 1-3 名患者提供起草的脚本和预后信息（目标是招募 90 名 1-3 岁的成年人） 76 至 89 岁）在就诊之前。我们将在这些访问后采访 PCP，以了解预后是否良好使用的信息以及 PCP 是否认为预后信息和/或指导脚本有用。我们还将在访问结束后采访老年人，了解他们对这些对话的看法以及他们的想法围绕癌症筛查的决策。 PCP 非常需要用于讨论的策略停止对老年人进行癌症筛查和长期预后，以便老年人可以赚更多钱关于他们的护理的明智决定并避免可能只会对他们造成伤害的医疗干预。