How Do Older Adults Consider Age,Life Expectancy,Quality of Life,and Physician Recommendations When Making Cancer Screening Decisions? Results from a National Survey Using a Discrete Choice Experiment
Restricted accessResearch articleFirst published online August, 2019
How Do Older Adults Consider Age,Life Expectancy,Quality of Life,and Physician Recommendations When Making Cancer Screening Decisions? Results from a National Survey Using a Discrete Choice Experiment
Background. Older adults with limited life expectancy frequently receive cancer screening, although on average, harms outweigh benefits. We examined the influence of life expectancy on older adults’ cancer screening decisions relative to three other factors. Methods. Adults aged 65+ years (N = 1272) were recruited from a national online survey panel. Using a discrete choice experiment, we systematically varied a hypothetical patient’s life expectancy, age, quality of life, and physician’s recommendation and asked whether the participant would choose screening. Participants were randomized to questions about colonoscopy or prostate-specific antigen/mammography screenings. Logistic regression produced preference weights that quantified the relative influence of the 4 factors on screening decisions. Results. 879 older adults completed the survey, 660 of whom varied their screening choices in response to the 4 factors we tested. The age of the hypothetical patient had the largest influence on choosing screening: the effect of age being 65 versus 85 years had a preference weight of 2.44 (95% confidence interval [CI]: 2.22, 2.65). Life expectancy (10 versus 1 year) had the second largest influence (preference weight: 1.64, CI: 1.41, 1.87). Physician recommendation (screen versus do not screen) and quality of life (good versus poor) were less influential, with preference weights of 0.90 (CI: 0.72, 1.08) and 0.68 (CI: 0.52, 0.83), respectively. Conclusions. While clinical practice guidelines increasingly use life expectancy in addition to age to guide screening decisions, we find that age is the most influential factor, independent of life expectancy, quality of life, and physician recommendation, in older adults’ cancer screening choices. Strategies to reduce overscreening should consider the importance patients give to continuing screening at younger ages, even when life expectancy is limited.
LeeSJBoscardinWJStijacic-CenzerIConell-PriceJO’BrienSWalterLC.Time lag to benefit after screening for breast and colorectal cancer: meta-analysis of survival data from the United States, Sweden, United Kingdom, and Denmark. BMJ. 2013;346:e8441.
2.
WalterLCCovinskyKE.Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 2001;285(21):2750–6.
3.
Lansdorp-VogelaarIGulatiRMariottoAB, et al. Personalizing age of cancer screening cessation based on comorbid conditions: model estimates of harms and benefits. Ann Intern Med. 2014;161(2):104–12.
4.
HarrisRPWiltTJQaseemA, High Value Care Task Force of the American College of Physicians. A value framework for cancer screening: advice for high-value care from the American College of Physicians. Ann Intern Med. 2015;162(10):712–7.
5.
EckstromEFeenyDHWalterLCPerdueLAWhitlockEP.Individualizing cancer screening in older adults: a narrative review and framework for future research. J Gen Intern Med. 2013;28(2):292–8.
6.
LinJSPiperMAPerdueLA, et al. Screening for colorectal cancer: updated evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA. 2016;315(23):2576–94.
7.
SiuAL, US Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2016;164(4):279–96.
8.
MoyerVA, US Preventive Services Task Force. Screening for prostate cancer: U.S. preventive services task force recommendation statement. Ann Intern Med. 2012;157(2):120–34.
9.
US Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;151(10):716–26, W-236.
10.
US Preventive Services Task Force. Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008;149(9):627–637.
11.
WolfAMWenderRCEtzioniRB, et al.; American Cancer Society Prostate Cancer Advisory Committee. American Cancer Society guideline for the early detection of prostate cancer: update 2010. CA Cancer J Clin. 2010;60(2):70–98.
12.
CarterHBAlbertsenPCBarryMJ, et al. Early detection of prostate cancer: AUA guideline. J Urol. 2013;190(2):419–26.
13.
QaseemADenbergTDHopkinsRHJr, et al.; Clinical Guidelines Committee of the American College of Physicians. Screening for colorectal cancer: a guidance statement from the American College of Physicians. Ann Intern Med. 2012;156(5):378–86.
14.
LeeCHDershawDDKopansD, et al. Breast cancer screening with imaging: recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer. J Am Coll Radiol. 2010;7(1):18–27.
15.
Moyer VA; US Preventive Services Task Force. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;156(12):880–91, W312.
16.
SaslowDSolomonDLawsonHW, et al.; ACS-ASCCP-ASCP Cervical Cancer Guideline Committee. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. CA Cancer J Clin. 2012;62(3):147–72.
17.
TonelliMConnor GorberSJoffresM, et al.; Canadian Task Force on Preventive Health Care. Recommendations on screening for breast cancer in average-risk women aged 40-74 years. CMAJ. 2011;183(17):1991–2001.
18.
SchonbergMABreslauESMcCarthyEP.Targeting of mammography screening according to life expectancy in women aged 75 and older. J Am Geriatr Soc. 2013;61(3):388–95.
19.
RoyceTJHendrixLHStokesWAAllenIMChenRC.Cancer screening rates in individuals with different life expectancies. JAMA Intern Med. 2014;174(10):1558–65.
20.
SchonbergMABreslauESHamelMBBellizziKMMcCarthyEP.Colon cancer screening in U.S. adults aged 65 and older according to life expectancy and age. J Am Geriatr Soc. 2015;63(4):750–56.
21.
PowellAASainiSDBreitensteinMK, et al. Rates and correlates of potentially inappropriate colorectal cancer screening in the Veterans Health Administration. J Gen Intern Med. 2015;30(6):732–41.
22.
DrazerMWPrasadSMHuoD, et al. National trends in prostate cancer screening among older American men with limited 9-year life expectancies: evidence of an increased need for shared decision making. Cancer. 2014;120(10):1491–8.
23.
SoCKirbyKAMehtaK, et al. Medical center characteristics associated with PSA screening in elderly veterans with limited life expectancy. J Gen Intern Med. 2012;27(6):653–60.
24.
LewisCLKistlerCEAmickHR, et al. Older adults’ attitudes about continuing cancer screening later in life: a pilot study interviewing residents of two continuing care communities. BMC Geriatr. 2006;6:10.
BakerLCBundorfMKSingerSWagnerTH.Validity of the Survey of Health and Internet and Knowledge Network’s Panel and Sampling. Stanford, CA: Stanford University; 2003
29.
ChangLKrosnickJA.National surveys via Rdd telephone interviewing versus the Internet: comparing sample representativeness and response quality. Public Opin Q. 2009;73(4):641–78.
30.
KrotkiKDennisJM.Probability-based survey research on the Internet. Paper presented at the 53rd Conference of the International Statistical Institute; August 22–29, 2001; Seoul Korea. Available from:http://www.knowledgenetworks.com/ganp/docs/ISI-2001-confernce-paper.pdf. Accessed January 2018.
31.
SchoenbornNLJanssenEMBoydCMBridgesJFPWolffACPollackCE.Preferred clinician communication about stopping cancer screening among older US adults: results from a national survey. JAMA Oncol. 2018;4(8):1126–8. doi:10.1001/jamaoncol.2018.2100
32.
SchoenbornNLBowmanTLCayeaDBoydCFeeserSPollackCE.Discussion strategies used by primary care clinicians when stopping cancer screening among older adults. J Am Geriatr Soc. 2016;64(11):e221–3.
33.
SchoenbornNLLeeKPollackCE, et al. Older adults’ views and communication preferences around cancer screening cessation. JAMA Intern Med. 2017;177(8):1121–8.
LewisCLKistlerCEAmickHR, et al. Older adults’ attitudes about continuing cancer screening later in life: a pilot study interviewing residents of two continuing care communities. BMC Geriatr. 2006;6:10.
36.
TarasenkoYNWackerbarthSBLoveMMJoyceJMHaistSA.Colorectal cancer screening: patients’ and physicians’ perspectives on decision-making factors. J Cancer Educ. 2011;26(2):285–93.
37.
HowardKSalkeldGPPatelMIMannGJPignoneMP.Men’s preferences and trade-offs for prostate cancer screening: a discrete choice experiment. Health Expect. 2015;18(6):3123–35.
38.
JohnsonFRLancsarEMarshallD, et al. Constructing experimental designs for discrete-choice experiments: report of the ISPOR Conjoint Analysis Experimental Design Good Research Practices Task Force. Value Health. 2013;16(1):3–13.
de Bekker-GrobEWRyanMGerardK.Discrete choice experiments in health economics: a review of the literature. Health Econ. 2012;21:145–72.
41.
ChewLDBradleyKABoykoEJ.Brief questions to identify patients with inadequate health literacy. Fam Med. 2004;36(8):588–94.
42.
McNaughtonCDCavanaughKLKripalaniSRothmanRLWallstonKA.Validation of a short, 3-item version of the subjective numeracy scale. Med Decis Making. 2015;35(8):932–6.
43.
CruzMCovinskyKWideraEWStijacic-CenzerILeeSJ.Predicting 10-year mortality for older adults. JAMA. 2013;309(9):874–6.
44.
WolffJLBoydCM.A look at person- and family-centered care among older adults: results from a national survey. J Gen Intern Med. 2015;30(10):1497–504.
45.
HallMAZhengBDuganECamachoFKiddKEMishraA, et al. Measuring patients’ trust in their primary care providers. Med Care Res Rev. 2002;59(3):293–318.
46.
KistlerCELewisCLAmickHRBynumDLWalterLCWatsonLC.Older adults’ beliefs about physician-estimated life expectancy: a cross-sectional survey. BMC Fam Pract. 2006;7:9. doi:10.1186/1471-2296-7-9
47.
HauberABGonzalezJMGroothuis-OudshoornCG, et al. Statistical methods for the analysis of discrete choice experiments: a report of the ISPOR Conjoint Analysis Good Research Practices Task Force. Value Health. 2016;19:300–15.
48.
MuhlbacherAJohnsonFR.Choice experiments to quantify preferences for health and healthcare: state of the practice. Appl Health Econ Health Policy. 2016;14:253–66.
49.
TorkeAMSchwartzPHHoltzLRMontzKSachsGA.Caregiver perspectives on cancer screening for persons with dementia: “why put them through it?”J Am Geriatr Soc. 2013;61(8):1309–14.
50.
BeydounHABeydounMA.Predictors of colorectal cancer screening behaviors among average-risk older adults in the United States. Cancer Causes Control. 2008;19:339–59.
51.
GandhiPKGentryWMKibertJL, et al. The relationship between four health-related quality of life indicators and use of mammography and Pap test screening in US women. Qual Life Res. 2015;24(9):2113–28.
52.
WilliamsBALindquistKSudoreRLCovinskyKEWalterLC.Screening mammography in older women: effect of wealth and prognosis. Arch Intern Med. 2008;168(5):514–20.
53.
HoffmanRMLewisCLPignoneM, et al. Decision-making processes for breast, colorectal, and prostate cancer screening: results from the DECISIONS study. Med Decis Making. 2010;30(5 Suppl):53S–64S.
54.
KjærTBechMGyrd-HansenDHart-HansenK. Ordering effect and price sensitivity in discrete choice experiments: need we worry?Health Econ. 2006;15:1217–28. doi:10.1002/hec.1117
55.
SchwartzLMWoloshinSFowlerFJJrWelchHG.Enthusiasm for cancer screening in the United States. JAMA. 2004;291(1):71–8.
56.
HoffmannTCDel MarC.Patients’ expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med. 2015;175(2):274–86. doi:10.1001/jamainternmed.2014.6016
57.
Sutkowi-HemstreetAVuMHarrisRBrewerNTDolorRJSheridanSL.Adult patients’ perspectives on the benefits and harms of overused screening tests: a qualitative study. J Gen Intern Med. 2015;30(11):1618–26.
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