Discussions of Prognosis and Stopping Cancer Screening in Older Adults

初级保健医生和执业护士(这里称为初级保健提供者，PCP)是 越来越多地被鼓励在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。最常见的医学方法之一 鼓励初级保健医生考虑老年人长期预后的干预措施是 决定进行癌症筛查。据估计，1,000名老年人需要进行乳房筛查(具体到 女性)或结肠癌，以避免在10年内死于这些癌症。由于这10年的滞后- 受益时间，指南建议预期寿命为10年的成年人不进行此类筛查 癌症。理由是这些患者不会活到足够长的时间来体验可能的生命延长。 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：假阳性测试引起的焦虑，过度诊断(检测到 没有威胁)，以及工作或癌症治疗的并发症。尽管如此，许多身材矮小的老年人 对预期寿命进行癌症筛查。其中一个原因是，初级保健医生避免与老年人谈论 停止癌症筛查。这些讨论需要考虑并经常讨论病人的生活。 预期和初级保健医生报告说，在评估和讨论老年人的预后时感到不舒服。 然而，通过避免这些讨论，初级保健医生可能会破坏他们的患者了解情况的能力 关于癌症筛查和其他医疗干预的决定。虽然有工具可用来帮助 PCP评估患者的预后，几乎没有信息来指导PCP如何讨论阻止癌症 老年人的筛查和长期预后。因此，在目标1中，我们计划开展重点小组和 与PCP(社区和学术)的个人访谈和对76至89岁的成年人的个人访谈 有5-10年的预期寿命，以了解他们对PCP应该如何做的想法、偏好和建议 与老年人讨论停止癌症筛查和长期预后的方法。然后我们将使用 这些数据用于制定战略和指导原则，供初级保健医生用于进行这些讨论，我们 将创建脚本以建议PCP在这些讨论期间使用的语言。在目标2中，我们将提供45 具有起草的剧本和1-3名患者的预后信息的初级保健医生(目标是招募90名年龄在 76至89岁)才去诊所就诊。我们将在这些访问后采访初级保健医生，以了解是否有预后 信息被使用，以及初级保健医生是否认为预后信息和/或指导脚本有用。我们 还将在这些访问后采访老年人，以了解他们对这些对话的看法和他们的 围绕癌症筛查的决策。初级保健医生很有必要使用战略来讨论 停止对老年人进行癌症筛查和长期预后，以便老年人可以做出更多 在知情的情况下决定他们的护理，避免可能只会对他们造成伤害的医疗干预。

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.