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Importance: Despite guideline recommendations, clinicians do not systematically use prior screening or health history to guide colorectal cancer (CRC) screening decisions in older adults., Objective: To evaluate the effect of a personalized multilevel intervention on screening orders in older adults due for average-risk CRC screening., Design, Setting, and Participants: Interventional 2-group parallel unmasked cluster randomized clinical trial conducted from November 2015 to February 2019 at 2 US Department of Veterans Affairs (VA) facilities: 1 academic VA medical center and 1 of its connected outpatient clinics. Randomization at the primary care physician/clinician (PCP) level, stratified by study site and clinical full-time equivalency. Participants were 431 average-risk, screen-due US veterans aged 70 to 75 years attending a primary care visit. Data analysis was performed from August 2018 to August 2023., Intervention: The intervention group received a multilevel intervention including a decision-aid booklet with detailed information on screening benefits and harms, personalized for each participant based on age, sex, prior screening, and comorbidity. The control group received a multilevel intervention including a screening informational booklet. All participants received PCP education and system-level modifications to support personalized screening., Main Outcomes and Measures: The primary outcome was whether screening was ordered within 2 weeks of clinic visit. Secondary outcomes were concordance between screening orders and screening benefit and screening utilization within 6 months., Results: A total of 436 patients were consented, and 431 were analyzed across 67 PCPs. Patients had a mean (SD) age of 71.5 (1.7) years; 424 were male (98.4%); 374 were White (86.8%); 89 were college graduates (21.5%); and 351 (81.4%) had undergone prior screening. A total of 258 (59.9%) were randomized to intervention, and 173 (40.1%) to control. Screening orders were placed for 162 of 258 intervention patients (62.8%) vs 114 of 173 control patients (65.9%) (adjusted difference, -4.0 percentage points [pp]; 95% CI, -15.4 to 7.4 pp). In a prespecified interaction analysis, the proportion receiving orders was lower in the intervention group than in the control group for those in the lowest benefit quartile (59.4% vs 71.1%). In contrast, the proportion receiving orders was higher in the intervention group than in the control group for those in the highest benefit quartile (67.6% vs 52.2%) (interaction P = .049). Fewer intervention patients (106 of 256 [41.4%]) utilized screening overall at 6 months than controls (96 of 173 [55.9%]) (adjusted difference, -13.4 pp; 95% CI, -25.3 to -1.6 pp)., Conclusions and Relevance: In this cluster randomized clinical trial, patients who were presented with personalized information about screening benefits and harms in the context of a multilevel intervention were more likely to receive screening orders concordant with benefit and were less likely to utilize screening., Trial Registration: ClinicalTrials.gov Identifier: NCT02027545.

While cancer screening guidelines increasingly recommend incorporating life expectancy estimates to inform screening decisions for older adults, little is known about how this happens in practice. This review summarizes current knowledge about primary care clinician and older adult (65+) perspectives about use of life expectancy to guide cancer screening decisions. Clinicians report operational barriers, uncertainty, and hesitation around use of life expectancy in screening decisions. They recognize it may help them more accurately weigh benefits and harms but are unsure how to estimate life expectancy for individual patients. Older adults face conceptual barriers and are generally unconvinced of the benefits of considering their life expectancy when making screening decisions. Life expectancy will always be a difficult topic for clinicians and patients, but there are advantages to incorporating it in cancer screening decisions. We highlight key takeaways from both clinician and older adult perspectives to guide future research.

Objectives: To assess patient preferences for colorectal cancer screening with stool-based tests after initial colonoscopy with suboptimal bowel preparation., Methods: An online scenario-based survey of adults aged 45 to 75 years at average risk for colorectal cancer was performed., Results: When presented with a hypothetical scenario of screening colonoscopy with suboptimal bowel preparation, 59% of respondents chose stool-based testing as a next step, 29% preferred a repeat colonoscopy within a year, and 12% preferred a repeat colonoscopy in 10 years (N = 1,080)., Conclusions: Clinicians should consider offering stool-based screening tests as an alternative to repeat colonoscopy after suboptimal bowel preparation.

Importance: Guidelines for colorectal cancer (CRC) screening recommend an individualized approach in older adults that is informed by consideration of life expectancy and cancer risk. However, little is known about how patients perceive individualized screening recommendations., Objective: To assess veterans' attitudes toward and comfort with cessation of low-value CRC screening (defined as screening in a patient for whom the benefit is expected to be small based on quantitative estimates from hypothetical risk calculators)., Design, Setting, and Participants: This survey study included patients older than 50 years who had undergone prior screening colonoscopy with normal results at the Veterans Affairs Ann Arbor Healthcare System. A total of 1500 surveys were mailed to potential participants from November 1, 2010, to January 1, 2012. Survey data were analyzed from January 1, 2016, to December 31, 2017., Main Outcomes and Measures: Response to the question, "If you personally had serious health problems that were likely to shorten your life and your doctor did not think screening would be of much benefit based on the calculator, how comfortable would you be with not getting any more screening colonoscopies?", Results: Of the 1500 surveys mailed, 85 were returned to sender, leaving 1415 potential respondents; 1054 of these respondents (median age range, 60-69 years; 884 [85.9%] white and 965 [94.2%] male) completed the survey (response rate, 74.5%). A total of 300 (28.7%) were not at all comfortable with cessation of low-value CRC screening, and 509 (49.3%) thought that age should never be used to decide when to stop screening. In addition, 332 (31.7%) thought it was not at all reasonable to use life expectancy calculators, and 255 (24.3%) thought it was not at all reasonable to use CRC risk calculators to guide these decisions. In ordered logistic regression analysis, factors associated with more comfort with screening cessation were (1) higher trust in physician (odds ratio [OR], 1.19; 95% CI, 1.07-1.32), (2) higher perceived health status (OR, 1.41; 95% CI, 1.23-1.61), and (3) higher barriers to screening (OR, 1.20; 95% CI, 1.11-1.30). Factors that were associated with less comfort with screening cessation included (1) greater perceived effectiveness of screening (OR, 0.86; 95% CI, 0.80-0.94) and (2) greater perceived threat of CRC (OR, 0.81; 95% CI, 0.73-0.89)., Conclusions and Relevance: The findings suggest that many veterans have strong preferences against screening cessation even when given detailed information about why the benefit may be low. Efforts to tailor screening recommendations may be met by resistance unless they are accompanied by efforts to address underlying perceptions about the benefit of screening.

Purpose: The recently developed Medical Maximizer-Minimizer Scale (MMS) assesses individual differences in preferences for active v. passive medical treatment. We hypothesized that men's maximizing-minimizing preferences might have relevance in the case of prostate-specific antigen (PSA) screening, since there is considerable variability in men's preference for being screened even among men who are informed that harm is more likely than benefit. The current research examined whether MMS preferences predict how men respond to didactic information and narrative stories about PSA screening., Design: US men 40+ years old ( N = 1208) participated in an online survey. Men viewed information about PSA screening in 3 phases and provided their preference for screening after each phase. Phase 1 described what PSA screening is. Phase 2 added didactic information about screening risks and benefits. Phase 3 added narrative stories; men were randomized to receive stories about 1) physical harm, 2) emotional harm, 3) overdiagnosis, or 4) all 3 stories. Participants also completed the validated MMS., Results: After receiving basic information, 76.8% of men wanted PSA screening. After receiving information about risks and benefits, 54.8% wanted screening (a significant reduction, P < 0.001). Men who changed their preferences were significantly more likely to be minimizers than maximizers; most men with maximizing tendencies wanted screening after both the didactic information and narratives, whereas most men with minimizing tendencies did not want the test after receiving information., Conclusions: Men who prefer a more minimizing approach to medicine are more responsive to evidence supporting limiting or forgoing screening than men who prefer a maximizing approach.

Objective: Little is known about the affective implications of communicating negative information about medical tests. This research explored how affective processes - particularly the Affect Heuristic and cancer anxiety - influence the way in which people respond to such information., Design: Participants received different types of information about PSA screening for prostate cancer and magnetic resonance imaging (MRI) scans for migraine headaches. This was a 2 (Test harm information: present vs. absent) × 2 (Test benefit information: present vs. absent) × 2 (Test recommendation: present vs. absent) between-participants design., Outcome Measures: Perceived risk, perceived benefit and general attitudes towards PSA and MRI testing, cancer anxiety, preferences to receive the tests vs. not., Results: As predicted by the Affect Heuristic, test harm information reduced perceived test benefits. However, information about uncertain test benefit did not increase perceived test risks. Information about the test reduced cancer anxiety, indicating defensive coping. These variables - affect, anxiety, perceived risks and benefits - all uniquely predicted test preferences., Conclusion: Affective processes play an important role in how people respond to and interpret negative information about medical tests. Information about harms and information about the lack of benefit can both make a test seem less beneficial, and will reduce cancer anxiety as a result.

Introduction: Engaging patients to make informed choices is paramount but difficult in busy practices. This study sought to engage patients outside the clinical setting to better understand how they approach cancer screening decisions, including their primary concerns and their preferences for finalizing their decision., Methods: Twelve primary care practices offering patients an online personal health record invited eligible patients to complete a 17-item online interactive module. Among 11,458 registered users, invitations to complete the module were sent to adults aged 50-74 years who were overdue for colorectal cancer screening and to women aged 40-49 years and men aged 55-69 who had not undergone a recent mammogram or prostate-specific antigen test, respectively., Results: The module was started by 2,355 patients and completed by 903 patients. Most respondents (76.8%) knew they were eligible for screening. Preferred next steps were talking to the clinician (76.6%), reading/research (28.6%), and consulting trusted friends/family (16.4%). Priority topics included how much screening improves life expectancy, comparative test performance, and the prevalence/health risks of the cancer. Leading fears were getting cancer/delayed detection (79.2%), abnormal results (40.5%), and testing complications (39.1%), the last referring to false test results, medical complications, or unnecessary treatments. Men eligible for prostate-specific antigen screening were more likely than women eligible for mammography to express concerns about testing complications and to prioritize weighing pros and cons over gut feelings (p<0.05)., Conclusions: Although this sample was predisposed to screening, most patients wanted help in finalizing their decision. Many wanted to weigh the pros and cons and expressed fears of potential harms from screening. Understanding how patients approach decisions may help design more effective engagement strategies., (Copyright © 2017 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Cancer prevention and screening guidelines are ideally suited to the task of providing high-quality benefit-harm information that informs clinical practice. We systematically examined how US guidelines present benefits and harms for recommended cancer prevention and screening interventions., Methods: We included cancer screening and prevention recommendations from: 1) the United States Preventive Services Task Force, 2) the American Cancer Society, 3) the American College of Physicians, 4) the National Comprehensive Cancer Network, and 5) other US guidelines within the National Guidelines Clearinghouse. Searches took place November 20, 2013, and January 1, 2014, and updates were reviewed through July 1, 2015. Two coders used an abstraction form to code information about benefits and harms presented anywhere within a guideline document, including appendices. The primary outcome was each recommendation's benefit-harm "comparability" rating, based on how benefits and harms were presented. Recommendations presenting absolute effects for both benefits and harms received a "comparable" rating. Other recommendations received an incomplete rating or an asymmetric rating based on prespecified criteria., Results: Fifty-five recommendations for using interventions to prevent or detect breast, prostate, colon, cervical, and lung cancer were identified among 32 guidelines. Thirty point nine percent (n = 17) received a comparable rating, 14.5% (n = 8) received an incomplete rating, and 54.5% (n = 30) received an asymmetric rating., Conclusions: Sixty-nine percent of cancer prevention and screening recommendation statements either did not quantify benefits and harms or presented them in an asymmetric manner. Improved presentation of benefits and harms in guidelines would better ensure that clinicians and patients have access to the information required for making informed decisions., (Published by Oxford University Press 2016. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Patients should understand the risks and benefits of cancer screening in order to make informed screening decisions., Objectives: To evaluate the extent of informed decision making in patient-provider discussions for colorectal (CRC), breast (BrCa), and prostate (PCa) cancer screening., Setting: National sample of US adults identified by random-digit dialing., Design: Cross-sectional survey conducted between November 2006 and May 2007., Participants: English-speaking US adults aged 50 y and older who had discussed cancer screening with a health care provider within the previous 2 y., Measurements: Cancer screening survey modules that asked about demographic characteristics, cancer knowledge, the importance of various sources of information, and self-reported cancer screening decision-making processes., Results: Overall, 1082 participants completed 1 or more of the 3 cancer modules. Although participants generally considered themselves well informed about screening tests, half or more could not correctly answer even 1 open-ended knowledge question for any given module. Participants consistently overestimated risks for being diagnosed with and dying from each cancer and overestimated the positive predictive values of prostate-specific antigen tests and mammography. Providers were the most highly rated information source, usually initiated screening discussions (64%-84%), and often recommended screening (73%-90%). However, participants reported that providers elicited their screening preferences in only 31% (CRC women) to 57% (PCa) of discussions. Although more than 90% of the discussions addressed the pros of screening, only 19% (BrCa) to 30% (PCa) addressed the cons of screening., Limitations: Recall bias is possible because screening process reports were not independently validated., Conclusions: Cancer screening decisions reported by patients who discussed screening with their health care providers consistently failed to meet criteria for being informed. Given the high ratings for provider information and frequent recommendations for screening, providers have important opportunities to ensure that informed decision making occurs for cancer screening decisions.

Background: Health behavior theories suggest that high perceived risk for cancer will be associated with screening, but few studies have examined how perceived risk relates to the screening decision process., Objective: To examine relationships between perceived risk of cancer and behaviors during decision making for 3 screening tests., Design: Cross-sectional survey conducted between November 2006 and May 2007., Setting: Nationwide random-digit dial telephone survey., Participants: A total of 1729 English-speaking US adults aged 40 y and older who reported making a cancer screening decision (about breast, colon, or prostate tests) in the previous 2 y., Measurements: Participants completed measures of perceived risk, information seeking, and shared decision-making tendencies., Results: As perceived risk for cancer increased, patients were more likely to seek information about screening on their own (e.g., 35% of participants who perceived a high risk of cancer searched the Internet compared with 18% for those who perceived a low risk, P < 0.001) and in interactions with their physicians. As perceived risk increased, patients were also more likely to consult with more than 1 provider. Gender moderated the shared decision-making preference such that men with high perceived risks were more likely than women with high perceived risks to report they would have preferred more involvement in the decision (35% v. 9%, P = 0.001)., Limitations: Cross-sectional data limit causal inferences., Conclusions: Higher perceived risk was associated with greater patient participation, as shown by more information seeking and greater desire for decisional involvement (moderated by gender). The results suggest that perceived risk of cancer could influence patient behavior when deciding about screening.

Objective: We sought to estimate what proportion of adults plan to stop cancer screening tests among adults who recently considered screening and to explore factors associated with these screening plans., Design: Telephone Survey, Participants: A total of 1,237 participants aged 50 and older who reported having made one or more cancer screening decisions in the past 2 years completed 1,454 cancer screening modules for breast, prostate and colorectal screening., Main Results: Of all module respondents, 9.8% reported plans to stop screening, 12.6% for breast, 6.0 % for prostate and 9.5% for colon cancer. We found no statistically significant differences in plans to stop for those ages >or=70 (8.2%) compared to those ages 50 to 69 (10.2%) (p = 0.14.) Black respondents were less likely to report plans to stop than white respondents (OR = 0.32, 95% CI 0.12, 0.87). Participation in the decision-making process was associated with plans to stop screening; those who reported they made the final decision about screening (OR 5.9, 95% CI 1.4, 24.7) or made the decision with the health care provider (OR 4.1, 95% CI 1.0, 16.8) were more likely to have plans to stop screening compared to respondents who reported that their health care provider made the final decision., Conclusions: Plans to stop screening were uncommon among participants who had recently faced a screening decision. Given the recent US Preventive Services Task Force recommendations limiting routine cancer screening for older adults, additional efforts to educate adults about the potential risks and benefits of screening may be warranted.

Narratives from similar others may be an effective way to increase important health behaviors. In this study, we used a narrative intervention to promote colorectal cancer screening. Researchers have suggested that people may overestimate barriers to colorectal cancer screening. We recruited participants from the US, ages 49-60 who had never previously been screened for colorectal cancer, to read an educational message about screening for the disease. One-half of participants were randomly assigned to also receive a narrative within the message (control participants did not receive a narrative). The narrative intervention was developed according to predictions of affective forecasting theory. Compared to participants who received only the educational message, participants who received the message along with a narrative reported that the barriers to screening would have less of an impact on a future screening experience. The narrative also increased risk perception for colorectal cancer and interest in screening in the next year., (Copyright (c) 2010 Elsevier Ltd. All rights reserved.)

Background: Cancer prevention and screening guidelines are ideally suited to the task of providing high-quality benefit-harm information that informs clinical practice. We systematically examined how US guidelines present benefits and harms for recommended cancer prevention and screening interventions.Methods: We included cancer screening and prevention recommendations from: 1) the United States Preventive Services Task Force, 2) the American Cancer Society, 3) the American College of Physicians, 4) the National Comprehensive Cancer Network, and 5) other US guidelines within the National Guidelines Clearinghouse. Searches took place November 20, 2013, and January 1, 2014, and updates were reviewed through July 1, 2015. Two coders used an abstraction form to code information about benefits and harms presented anywhere within a guideline document, including appendices. The primary outcome was each recommendation's benefit-harm "comparability" rating, based on how benefits and harms were presented. Recommendations presenting absolute effects for both benefits and harms received a "comparable" rating. Other recommendations received an incomplete rating or an asymmetric rating based on prespecified criteria.Results: Fifty-five recommendations for using interventions to prevent or detect breast, prostate, colon, cervical, and lung cancer were identified among 32 guidelines. Thirty point nine percent (n = 17) received a comparable rating, 14.5% (n = 8) received an incomplete rating, and 54.5% (n = 30) received an asymmetric rating.Conclusions: Sixty-nine percent of cancer prevention and screening recommendation statements either did not quantify benefits and harms or presented them in an asymmetric manner. Improved presentation of benefits and harms in guidelines would better ensure that clinicians and patients have access to the information required for making informed decisions. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To identify patient- and decision-type predictors of two key aspects of informed decision making: discussing the cons (not just the pros) of medical interventions and asking patients what they want to do. Methods: Using data from 2473 members of the DECISIONS survey, a nationally representative sample of U.S. adults age 40+, we used logistic regression analysis to identify which patient characteristics predicted patient reports of healthcare providers discussing cons or eliciting preferences about one of 9 common medical decisions. Results: Multiple demographic characteristics predicted both discussions of cons and elicitations of preferences, although the specific characteristics varied between decision contexts. In particular, African-American respondents reported being more likely to receive a discussion of the cons of cancer screening (OR=1.69, p <0.05) yet less likely to have been asked their opinion about either getting a cancer screening test (OR=0.56, p <0.05) or initiating medications (OR=0.53, p <0.05). Significant cross-decision variations remained even after controlling for patient characteristics. Conclusions: Important disparities in patient communication and involvement appear to exist both between different types of medical decisions and between different types of patients. Practice implications: Providers must make sure to consistently discuss the cons of treatment and to solicit input from all patients, especially African-Americans. [Copyright &y& Elsevier]