Assessment of Clinician Decision-making on Cancer Screening Cessation in Older Adults With Limited Life Expectancy

This qualitative study uses medical record-stimulated recall to examine primary care clinicians' decision-making on stopping cancer screening in specific older patients with limited life expectancy. Question How do clinicians and patients think about stopping cancer screening in older adults with limited life expectancy? Findings In this mixed methods study with 25 clinicians and 47 patients, cancer screening decisions were found to be not always conscious or deliberate. When the decisions were deliberate, they were associated with not only patient characteristics, but also subjective factors such as patient request, clinicians' anecdotal experiences, and the patients' family and friends. Meaning In this study, findings suggest that strategies to facilitate more deliberate decision-making may be important in cancer screening of older adults with limited life expectancy. Importance Despite clinical practice guidelines recommending against routine cancer screening in older adults with limited life expectancy, older adults are still frequently screened for breast, colorectal, and prostate cancers. Objective To examine primary care clinicians' decision-making on stopping breast, colorectal, or prostate cancer screening in older adults with limited life expectancy. Design, Setting, and Participants In qualitative interviews coupled with medical record-stimulated recall, clinicians from 17 academic and community clinics affiliated with a large health system were asked how they came to specific cancer screening decisions in 2 or 3 of their older patients with less than 10-year of estimated life expectancy, including patients with and without recent screening. Patients were surveyed by telephone. Data collection occurred between October 2018 and May 2019. Main Outcomes and Measures Clinician interviews were audio-recorded and transcribed verbatim. Transcripts were analyzed with qualitative content analysis to identify major themes. Patient surveys assessed perception of cancer screening decisions, importance of clinician recommendation, and willingness to stop screening. Results Twenty-five primary care clinicians (mean [SD] age, 47.1 [9.7] years; 14 female [56%]) discussed 53 patients during medical record-stimulated recall, ranging from 2 to 3 patients per clinician; 46 patients and 1 caregiver (mean [SD] age 74.9 [5.4]; 31 female [66%]) participated in the survey. Clinician interviews revealed 5 major themes: (1) cancer screening decisions were not always conscious, deliberate decisions; (2) electronic medical record alerts were connected with less deliberate decision-making; (3) cancer screening was not binary and clinicians often considered other options to scale back screening without actually stopping; (4) in addition to patient characteristics, clinicians were influenced by patient request and anecdotal experiences; and (5) influences outside of the primary care clinician-patient dyad were important, such as from specialists and patients' family or friends. Patient surveys asked approximately 64 cancer screening decisions of 47 patients. Patients did not recall approximately half (31 of 64) of their cancer screening decisions. Among those with recent screening, the mean score for willingness to stop screening was 3.2 (95% CI 2.5-3.9) on a 5-point Likert scale (with 1 indicating extremely unlikely and 5 indicating extremely likely). In most screening decisions that involved specialists (13 of 16), patients valued specialists' recommendations over those of primary care clinicians. Conclusions and Relevance Cancer screening decision-making is complex. Study findings suggest that strategies that facilitate more deliberate decision-making may be important in cancer screening of older adults with limited life expectancy.