DISCUSSION STRATEGIES THAT PRIMARY CARE CLINICIANS USE WHEN STOPPING CANCER SCREENING IN OLDER ADULTS

To the Editor

Research and clinical practice guidelines increasingly call for ceasing cancer screening in older adults with limited life expectancy to minimize harm,^1–6 but rates of cancer screening in older adults with limited life expectancy remain high.⁷ One potential contributor to overscreening may be clinician discomfort with discussing discontinuation of cancer screening with patients. This study aims to examine how primary care clinicians discuss stopping cancer screening in older adults with limited life expectancy.

METHODS

Semistructured, in-depth interviews were conducted with 28 primary care clinicians from a large group practice between January and May 2015. The sampling strategy combined maximum variation and snowball sampling. Audiorecordings of the interviews were transcribed verbatim. Part of each interview explored how clinicians considered life expectancy in the care of older adults; the related results have been reported elsewhere.⁸ Herein, the part of the interview in which clinicians were asked to describe their approaches to discussing discontinuation of cancer screening in older adults with limited life expectancy and their perceptions of the responses is focused on. Iterative assessment for theme saturation in the data guided data collection. Two investigators (NS, TB) independently coded all transcripts using qualitative content analysis to generate major themes and reconciled differences using consensus.

RESULTS

The 28 participants from 14 clinic sites had an average age of 46.2; 16 were female, and 21 were white. Participants included two certified registered nurse practitioners and 26 physicians. Twenty self-reported that at least one-quarter of their patient panel was older adults.

When clinicians suggested stopping cancer screening in individuals with limited life expectancy, they did not always make their suggestion explicit. Some clinicians chose to omit cancer screening from discussion, and others used subtle hints such as saying: “You don’t want this [cancer screening], do you?” (Table 1). The clinicians that explicitly suggested stopping cancer screening commonly focused the discussion on the risk-benefit ratio of screening or quality of life (Table 1) but often did not discuss life expectancy per se. For example, one clinician said, “I say: ‘We’re finished with colonoscopies’ … if I don’t feel like they have all that long to live, … but I don’t explicitly say why. … I just do that calculation in my head.”

Table 1.

Primary Care Clinicians’ Approaches to Discussing Stopping Cancer Screening in Older Adults with Limited Life Expectancy

Discussion Approach	Example
Content of discussion
Focus on risks and benefits	I don’t ever say specifically I don’t think that you’re gonna live this long. I say ‘[given] the risk benefit ratio at this age I don’t think [cancer screening] is necessary, I don’t think we need to do it.’
Focus on quality of life	I’d like to focus on making your quality of life good, I don’t want to put you through unnecessary suffering … cancer screening can be very beneficial for detecting early cancers but when you are older and have other medical issues if you find something, [they] really are not able to give you any treatment so instead of doing that let’s focus on what we can do to make you feel better.
Focus on more active medical typo - concerns	The way I frame the conversation is: ‘let’s shift the focus to things that are more relevant right now’… I don’t specifically say: ‘I don’t think you’re gonna live for the next 5 years.’
Inquire if interested in downstream testing	If they have limited life expectancy… I would say: ‘the mammogram shows cancer, now what do you want to do?’ And they say: ‘oh well I didn’t think about that.’ I say: ‘ok if you are not gonna do anything with the answers then it’s putting you under radiation exposure that you don’t need, costing you money that you don’t have, and squishing parts that you don’t want squished.’
Omit from discussion	Sometimes it’s just best to let sleeping dogs lie and [cancer screening] just isn’t a part of the discussion anymore.
Style of discussion
Give patient permission to stop	With my sicker 65 [year old patient], I would say: ‘do you want to do this? It’s ok if you don’t want to do it.’ With my healthier [patient], it would be: ‘you’re due for it, do you want me to order it today?’
Subtle suggestion	I might ask the question like: ‘you don’t really want this do you?’… that way implying that I don’t really think you are [interested in screening] but I’m not gonna deny it if you want it.
Negotiation	I still enter negotiations if a woman says: ‘but I’ve been doing [mammograms] every year for 20 or 30 or 40 years.’ I say: ‘why don’t we do this one more, but I’ll have the same advice [to stop screening] next year.’
Assertiveness	If they’re really sick, … I’m more assertive: ‘I don’t think that you need to get these tests done, they are not indicated for you, they are not going to help you.’

When clinicians mentioned life expectancy, they framed it in relative terms as how cancer screening would affect life expectancy as opposed to presenting life expectancy in absolute numbers. For example, one clinician said, “If we do [prostate-specific antigen] screening, we may be able to find cancer earlier, … but we may not be altering your life expectancy.”

Clinicians described that some patients were relieved or happy to stop cancer screening: “Most of them are rather relieved … when some screening tests just aren’t felt to be worthwhile anymore.”

Other clinicians commented that patients responded with skepticism or resistance: “This 89-year-old lady [said,] ‘Why am I not supposed to get mammograms anymore? I want to get mammograms, I think [the doctors] are giving up on me.’”

In the face of resistance, clinicians often gave in to requests: “I say: ‘You may not need [this screening test].’ But if the patient is really keen on it, I give it to them.”

DISCUSSION

To the knowledge of the authors, this study is the first to explore how primary care clinicians discuss stopping cancer screening in older adults with limited life expectancy. Without clear guidelines on how to approach these conversations, clinicians employed a variety of discussion strategies. Some clinicians relied on strategies that did not explicitly mention the recommendation to stop cancer screening, and others focused the discussion on the harms and benefits of screening rather than life expectancy itself. These findings suggest the need for more guidance on the type and amount of information that should be shared during these discussions. Examining patient perspectives on what constitutes effective communication strategies when discontinuing cancer screening is a crucial next step.

Clinicians reported that although some patients desired continued screening, others were relieved to stop screening. A prior survey of primary care clinicians found that the largest barrier to stopping prostate cancer screening was that patients expected to continue getting tested.⁹ The current study suggests that at least some clinicians are able to discuss the issue in a way in which they perceive that patients are comfortable with stopping screening. This is encouraging because a previous study suggested that patients considered cancer screening morally obligatory and found it “strange” to stop cancer screening.¹⁰

Participants in this study were from one group practice and may not be representative of clinicians elsewhere. The study design relied on self-report, and the results are prone to recall and social desirability bias.

Despite increasing clinical practice guideline recommendations to incorporate life expectancy into cancer screening decisions,^1–6 clinicians rarely communicate life expectancy when discussing discontinuation of cancer screening. Future research needs to better define best practices for how to discuss cancer screening cessation in people with limited life expectancy.