Targeted decision aids may not impact CRC screening preference among older adults
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Although decision aids helped inform older adults about potential benefits and risks associated with colorectal cancer screening, the tools did not significantly influence patient preference for screening, regardless of health.
“Since 2008, the U.S. Preventive Services Task Force has recommended individualized decision making for CRC screening for adults aged 76 to 84 years, a process that includes
a consideration of health state and patient preferences. Because CRC is typically a slow-growing cancer, the benefits from early detection of polyps accrue 5 to 10 years after undergoing CRC screening,” Alexandra F. Dalton, PhD, of the division of general internal medicine at the University of Colorado School of Medicine, and colleagues wrote in JAMA Network Open. “It is in an older patient’s best interest to be informed about the potential benefits and harms of screening associated with age and comorbidity when making a decision about CRC screening instead of reflexively continuing to undergo screening tests.”
In a secondary analysis of a randomized clinical trial, Dalton and colleagues aimed to determine whether targeted decision aids would influence CRC screening preference in older adults. Researchers recruited 424 participants (mean age, 76.8 years; 58.5% women, 78.5% white) from 14 community-based primary care practices, all of whom were not current on screening and had an appointment within 6 weeks of the study period.
Researchers assigned 212 participants to the intervention group and 209 participants to the control group; they further stratified patients by good (n = 74 and 75, respectively), intermediate (n = 76 and 73) and poor (n = 62 and 61) health states.
According to analysis, fewer participants in the intervention group preferred screening compared with the control group (48.1% vs. 56.9%), although the difference was not significant.
By health state, researchers reported a similar proportion of participants in a good health state who preferred screening between groups (59.5% vs. 61.3%), while fewer participants in both the intermediate (44.7% vs. 54.8%) and poor (38.7% vs. 54.1%) health states preferred screening in the intervention vs. control group.
“The findings of this secondary analysis of a randomized clinical trial did not demonstrate statistically significant differences in patient preferences between health state groups,” Dalton and colleagues concluded. “The proportion of participants in intermediate and poor health states who preferred screening decreased after engaging with the decision aid compared with those who received the control materials, but these differences were not statistically significant.”
They continued, “Additional studies that are appropriately powered are needed to determine the effect of the decision aid on preferences of older patients for CRC screening by health state.”
Perspective
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Mohamad Mouchli, MD
This study confirms the importance of engaging older patients in decision-making and discussing the pros and cons of screening colonoscopy in their age group. It also suggests that preference might change based on the health state of the patient.
Discussing screening colonoscopy with patients older than 75 years can be challenging. It is a gray area for physicians, since the net benefit is small, per the U.S. Preventive Services Task Force. There is evidence that screening beyond age 75 years could be beneficial in decreasing CRC incidence and mortality by 40% when compared with patients in the same age group who did not undergo colonoscopy/sigmoidoscopy, per a large observational study published in 2021 in JAMA Oncology. There was no clear evidence to support the decrease in CRC mortality among patients with multiple underlying health conditions.
I address this on a case-by-case basis, per the USPSTF recommendations, and ask my patients to make the decision. Physicians should always discuss potential complications — such as bowel preparation complications, delayed perforation, heavy bleeding, adverse medication reactions and bacterial infection — that are unique for older patients. I do not usually offer an at-home noninvasive test to screen for CRC in this group, since advanced age is associated with increased changes in DNA methylation and false positive tests are common.
More prospective studies are needed to help individualize screening in this population.
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