Discussions of Prognosis and Stopping Cancer Screening in Older Adults

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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.