Exploring factors that might influence primary-care provider discussion of and recommendation for prostate and colon cancer screening

Christine E Kistler,1 Maihan Vu,2 Anne Sutkowi-Hemstreet,3 Ziya Gizlice,4 Russell P Harris,5 Noel T Brewer,6 Carmen L Lewis,7 Rowena J Dolor,8 Colleen Barclay,5 Stacey L Sheridan9 1Department of Family Medicine, School of Medicine, 2Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, 3Napa County Office of Education, Napa, CA, 4Biostatistical Support Unit, Center for Health Promotion and Disease Prevention, 5Cecil G Sheps Center for Health Services Research, 6Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, 7Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, 8Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, 9Reaching for High Value Care Team, Chapel Hill, NC, USA Background: Primary-care providers may contribute to the use of low-value cancer screening. Objective: We sought to examine circumstances under which primary-care providers would discuss and recommend two types of cancer screening services across a spectrum of net benefit and other factors known to influence screening. Patients and methods: This was a cross sectional survey of 126 primary-care providers in 24 primary-care clinics in the US. Participants completed surveys with two hypothetical screening scenarios for prostate or colorectal cancer (CRC). Patients in the scenarios varied by age and screening-request status. For each scenario, providers indicated whether they would discuss and recommend screening. Providers also reported on their screening attitudes and the influence of other factors known to affect screening (short patient visits, worry about lawsuits, clinical reminders/performance measures, and screening guidelines). We examined associations between providers’ attitudes and their screening recommendations for hypothetical 90-year-olds (the lowest-value screening). Results: Providers reported they would discuss cancer screening more often than they would recommend it (P<0.001). More providers would discuss and recommend screening for CRC than prostate cancer (P<0.001), for younger than older patients (P<0.001), and when the patient requested it than when not (P<0.001). For a 90-year-old patient, every point increase in cancer-specific screening attitude increased the likelihood of a screening recommendation (30% for prostate cancer and 30% for CRC). Discussion: While most providers’ reported practice patterns aligned with net benefit, some providers would discuss and recommend low-value cancer screening, particularly when faced with a patient request. Conclusion: More work appears to be needed to help providers to discuss and recommend screening that aligns with value. Keywords: cancer screening, older adults, decision making, low-value care, colon cancer, prostate cance

Adult Patients’ Perspectives on the Benefits and Harms of Overused Screening Tests: a Qualitative Study

BACKGROUND: In recent years, there has been a growing interest in reducing the overuse of healthcare services. However, little is known about how patients conceptualize the benefits and harms of overused screening tests or how patients make decisions regarding these tests. OBJECTIVE: To determine how patients think about the harms and benefits of overused screening tests and how they consider these and other factors when making decisions. DESIGN: Semi-structured, qualitative interviews. PARTICIPANTS: The study comprised 50 patients, ages 50–84, who had previously received or not received any of four overused screening services: 1) prostate cancer screening (men ages 50–69), 2) colon cancer screening (men and women ages 76–85), 3) osteoporosis screening (low-risk women ages 50–64), or 4) cardiovascular disease screening (low-risk men and women ages 50–85). APPROACH: We conducted a thematic analysis, using a hybrid inductive-deductive approach. Two independent coders analyzed interview transcriptions to identify themes and exemplifying quotes. KEY RESULTS: Many patients could not name a harm of screening. When they did name harms, patients often focused on only the harms of the screening test itself and rarely mentioned harms further along the screening cascade (e.g., from follow-up testing and treatment). In contrast, patients could easily name benefits of screening, although many seemed to misunderstand or overestimate the magnitude of the benefits. Furthermore, patients described many additional factors they considered when making screening decisions, including their clinicians’ recommendations, their age, family or friends’ experiences with disease, and insurance coverage. CONCLUSIONS: This study highlights the need to help adults recognize and understand the benefits and harms of screening and make appropriate decisions about overused screening tests