As people age and their comorbidities accumulate, medical decisions become more complex, as do conversations about medical tests, such as cancer screening tests. For older adults who have a long life expectancy, continued screening may make sense, whereas for others, it may not. Clinicians and patients do not have clear guidelines on whether to continue or stop colorectal cancer (CRC) screening for older adults. For patients 75 and older, the US Preventive Services Task Force advises that CRC screening be an individual decision based on the patient’s preferences, prior history of screening, and life expectancy.
Patient registries have been built into electronic health records and are effective interventions to support implementation of cancer screening guidelines for patients aged 50–74. However, after age 75, patients are typically excluded from these registries. Extending registries to include this older population may prompt clinicians to engage patients in discussions about screening. As recommended in the guidelines, shared decision making (SDM) is one approach to discuss continued cancer screening. However, the registry alone may not be enough to promote SDM, as studies show considerable gaps in clinicians’ ability to inform and meaningfully involve patients in cancer screening decisions. More support to train clinicians in SDM skills may be needed to ensure informed, patient-centered decisions.
The main project goals are to (1) ensure that older adults are well informed and involved in decisions about whether to continue CRC screening, (2) measure the effects of the interventions on cancer screening rates, and (3) compare the effectiveness of different decision support strategies on providers’ confidence in conducting SDM with older patients.
Patient partners helped design this study and selected the primary outcome—the effectiveness of the interventions in improving the amount of SDM in conversations about CRC screening. We will recruit 50 clinicians across academic and community sites and randomly assign them to one of two interventions, (1) a traditional cancer registry that provides a report of the cancer screening status of their patients aged 76–85 and (2) the registry plus an online SDM skills training course that includes practice with simulated patients. We will enroll about 500 eligible patients of participating clinicians and examine the effectiveness of the interventions on patients’ reports of shared decision making and on the percentage of patients who receive their preferred approach to cancer screening. We will also examine clinicians’ confidence and ability to demonstrate SDM skills in cancer screening discussions.
We have engaged patient partners, along with clinician stakeholders with expertise in primary care, geriatrics, and CRC screening and treatment, at each stage of study development. The study will provide important new evidence about shared decision making in a new clinical area—how to determine when it might be appropriate for a patient to discontinue cancer screening—with an understudied population, adults aged 76–84. Better decisions about whether or when to stop tests may reduce unnecessary tests and treatments and allow patients to avoid side effects and potential harms. The results will also have wide-reaching implications for use of shared decision making in many other decisions for older adults, such as continuing mammography or prostate cancer screening and continuing medications for high cholesterol or hypertension.
Training and Education Interventions