Guidelines recommend against routine screening for breast, colorectal, and prostate cancers in older adults with less than 10 years of life expectancy. However, clinicians often continue to recommend cancer screening for these patients. We examined primary care clinicians' perspectives regarding overscreening, as defined by limited life expectancy.
Semistructured, in-depth individual interviews.
Twenty-one academic and nonacademic primary care clinics in Maryland.
Thirty primary care clinicians from internal medicine, family medicine, medicine/pediatrics, and geriatric medicine.
Interviews explored whether the clinicians believed that overscreening for breast, colorectal, or prostate cancers existed in older adults and their views on using life expectancy to decide on stopping routine screening. Audio recordings of the interviews were transcribed verbatim. Two investigators independently coded all transcripts using qualitative content analysis.
Most clinicians were physicians (24/30) and women (16/30). Content analysis generated three major themes. (1) Many, but not all, clinicians perceived overscreening in older adults as a problem. (2) There was controversy around using limited life expectancy to define overscreening due to concerns that the guidelines did not capture potential nonmortality benefits of screening; that population-based screening data could not be easily applied to individuals; that this approach failed to account for patient choice; and that life expectancy predictions were inaccurate. (3) Some clinicians worried that using life expectancy to define overscreening may inadvertently introduce bias and lead to unintended harms.
Several clinicians disagreed with guideline frameworks of using limited life expectancy to guide cancer screening cessation. Some disagreement stems from inadequate knowledge about the benefits and harms of cancer screening and indicates a need for education or decision support. Other reasons for disagreement highlight the need to refine the current recommended cancer screening approaches and identify strategies to avoid unintended consequences, such as introducing bias or exacerbating existing disparities.
Journal of the American Geriatrics Society. 2020 Mar 31 [Epub ahead of print]
Nancy L Schoenborn, Jacqueline Massare, Reuben Park, Craig E Pollack, Youngjee Choi, Cynthia M Boyd
Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA., The Johns Hopkins University, Baltimore, Maryland, USA., Department of Healthy Policy and Management, The Johns Hopkins University School of Public Health, Baltimore, Maryland, USA.