Barriers to Cancer Prevention in the Older Person

Factors influencing general practitioners in the referral of elderly cancer patients

BACKGROUND

A number of studies have identified advanced age as a barrier to accessing specialised oncological care. Many factors can influence the care provided for elderly patients after a diagnosis of cancer has been established or is suspected. Only one European study has analysed the decision processes leading general practitioners (GPs) to refer elderly patients with cancer to oncologists. The objectives of the current study are to describe the factors that influence these decisions and to identify the particular factors and GP characteristics that are associated with systematic referral of these patients in South-West France.

METHODS

This is a cross-sectional study on a representative sample of GPs in Aquitaine, South-West France. Questionnaire items were selected using a Delphi consensus approach and sent by post. Two logistic regression models were constructed to investigate GPs' decisions to refer these patients.

RESULTS

The response rate obtained was 30%. Half of the general practitioners reported "always" referring their elderly cancer patients to oncologists. More than 75% reported being influenced by patient-related elements (patient and/or family wishes, comorbid factors, unsuitability of invasive investigations, physical and mental autonomy), by cancer-related elements (severity of symptoms, expected side-effects) and an organisational element (whether the general practitioner was used to collaborating with oncologists). Logistic regression analysis showed that cancer site and organisational difficulties in patient management were significantly associated with the decision to refer elderly patients with early-stage cancer. For advanced stages, oncology training, patient age, organisational difficulties in patient management and stage of cancer were significantly associated with the decision to refer elderly patients.

CONCLUSIONS

Cancer-linked factors and organisational difficulties have been highlighted as influencing the decisions of GPs in the referral of elderly patients to a cancer team. These results highlight the need to implement continuous medical education specific for the management of elderly patients, to better apprehend the nature of these difficulties and to suggest solutions suited to local settings.

Estimated time spent on preventive services by primary care physicians

BACKGROUND

Delivery of preventive health services in primary care is lacking. One of the main barriers is lack of time. We estimated the amount of time primary care physicians spend on important preventive health services.

METHODS

We analyzed a large dataset of primary care (family and internal medicine) visits using the National Ambulatory Medical Care Survey (2001-4); analyses were conducted 2007-8. Multiple linear regression was used to estimate the amount of time spent delivering each preventive service, controlling for demographic covariates.

RESULTS

Preventive visits were longer than chronic care visits (M = 22.4, SD = 11.8, M = 18.9, SD = 9.2, respectively). New patients required more time from physicians. Services on which physicians spent relatively more time were prostate specific antigen (PSA), cholesterol, Papanicolaou (Pap) smear, mammography, exercise counseling, and blood pressure. Physicians spent less time than recommended on two "A" rated ("good evidence") services, tobacco cessation and Pap smear (in preventive visits), and one "B" rated ("at least fair evidence") service, nutrition counseling. Physicians spent substantial time on two services that have an "I" rating ("inconclusive evidence of effectiveness"), PSA and exercise counseling.

CONCLUSION

Even with limited time, physicians address many of the "A" rated services adequately. However, they may be spending less time than recommended for important services, especially smoking cessation, Pap smear, and nutrition counseling. Future research is needed to understand how physicians decide how to allocate their time to address preventive health.

The impact of health status on physicians' intentions to offer cancer screening to older women

BACKGROUND

Screening for breast and cervical cancer reduces disease-specific mortality, but high rates of comorbidity and disability among elderly persons may alter the risks and benefits of screening.

METHODS

We performed a mail survey of primary care physicians to estimate the impact of health status on physicians' intentions to offer cancer screening to older women. Respondents were asked to read a scenario about an older woman. Each scenario patient was one of three ages (70, 80, or 90) and had one of three levels of comorbidity and disability. Respondents were asked to estimate the likelihood of offering screening with mammography and Pap smear to these patients on a 5-point Likert scale. A logistic regression compared those physicians somewhat or very likely to offer screening with those less likely to do so. Further analyses examined the characteristics of physicians likely to "overscreen" the frailest older women (<5 years median life expectancy) or "underscreen" the healthiest (>10 years median life expectancy).

RESULTS

Respondents returned 2003 completed surveys (37.4%). Controlling for age and prior screening, higher levels of comorbidity and disability were associated with a significantly lower likelihood of offering screening for both mammography and Pap smear. Nonetheless, a substantial percentage (30.7%) of physicians indicated a high likelihood of offering a frail 90-year-old woman a mammogram, and 13.4% would offer her a Pap smear. In general, overscreening was more common than underscreening. Female gender was associated with "overscreening" with mammography, whereas male gender and lack of board certification predicted "underscreening." Lack of board certification was associated with "overscreening" with Pap smear.

CONCLUSIONS

In addition to age, primary care physicians consider health status in deciding to offer cancer screening to older women. Education and guidelines for cancer screening should more explicitly address the risks of overscreening among frail older women.

Older adults' attitudes about continuing cancer screening later in life: a pilot study interviewing residents of two continuing care communities

Background

Individualized decision making has been recommended for cancer screening decisions in older adults. Because older adults' preferences are central to individualized decisions, we assessed older adults' perspectives about continuing cancer screening later in life.

Methods

Face to face interviews with 116 residents age 70 or over from two long-term care retirement communities. Interview content included questions about whether participants had discussed cancer screening with their physicians since turning age 70, their attitudes about information important for individualized decisions, and their attitudes about continuing cancer screening later in life.

Results

Forty-nine percent of participants reported that they had an opportunity to discuss cancer screening with their physician since turning age 70; 89% would have preferred to have had these discussions. Sixty-two percent believed their own life expectancy was not important for decision making, and 48% preferred not to discuss life expectancy. Attitudes about continuing cancer screening were favorable. Most participants reported that they would continue screening throughout their lives and 43% would consider getting screened even if their doctors recommended against it. Only 13% thought that they would not live long enough to benefit from cancer screening tests. Factors important to consider stopping include: age, deteriorating or poor health, concerns about the effectiveness of the tests, and doctors recommendations.

Conclusion

This select group of older adults held positive attitudes about continuing cancer screening later in life, and many may have had unrealistic expectations. Individualized decision making could help clarify how life expectancy affects the potential survival benefits of cancer screening. Future research is needed to determine whether educating older adults about the importance of longevity in screening decisions would be acceptable, affect older adults' attitudes about screening, or change their screening behavior.

An intervention study to increase colorectal cancer knowledge and screening among community elders

This study evaluates the effectiveness of a culturally relevant intervention, delivered over 12 months on knowledge of colorectal cancer and participation in fecal occult blood testing. An experimental, repeated measures design was used. Free fecal occult blood testing was offered to the participants. Fifteen senior centers were randomly selected and assigned to the Cultural and Self-Empowerment Group, the Modified Cultural Group, or the Traditional Group. Their mean age was 73.83 years, and their average educational level was 8.8 years. The majority was African American, female, and reported annual incomes < or = 10,000 dollars. Data were collected at baseline, at 6 months, and at 12 months. Participants in the Cultural and Self-Empowerment Group had a significantly greater increase in their knowledge of colorectal cancer over time. Group membership and knowledge of colorectal cancer were significant predictors of participation in colorectal cancer screening. Participants in the Cultural and Self-Empowerment Group and those with greater knowledge of colorectal cancer were more likely to participate in fecal occult blood testing at the end of the 12-month period. Similar strategies may be implemented in community settings and health care agencies to inform elders about colorectal cancer.

Cancer in the elderly: is it preventable?

It is the goal of the American Cancer Society to decrease the mortality from cancer by 50% and the incidence of cancer by 25% by the year 2015 in the United States. Achieving this goal requires intervention at the primary (incidence) and secondary (mortality) prevention stages, and will involve a concerted effort of the individual practitioner, governmental agencies, local, state, and national interest groups, and the population at large. Primary care practitioners must increase their level of enthusiasm for cancer prevention, and actively counsel patients about cancer risks and preventive measures. Practitioners should encourage inclined patients by providing support and specialty resources, such as dieticians, exercise therapists, and smoking and alcohol cessation programs. The greatest effort lies in the general population, who must adopt a healthier lifestyle, including appropriate diet, smoking cessation, control of obesity, and daily exercise. None of these lifestyle changes are easy to embrace, but once educated about lifestyle and risk of cancer, people have a powerful incentive to change. Continued public awareness campaigns and encouragement from health care providers are essential for the success of such programs. The success in smoking cessation shows that achieving societal lifestyle changes on a large scale is possible. The elderly are especially prone to benefit from primary and secondary prevention techniques, and it must not be assumed that only the young will realize the benefits of prevention and screening. The association of age and cancer risk will always be present, but need not be as consequential as it is now. Although cancer prevention may have a limited role in antiaging per se, the feasibility of cancer risk reduction has a definite role in aging successfully.

Relationships of practitioner communications and characteristics with women's mammography use

Women have reported not seeking mammography because their practitioners do not recommend it. The purposes of this study were to delineate which dimensions of practitioner communications and characteristics predicted women's mammography use. In a longitudinal, correlational design, participants were 797 mid-western women, aged 51-80 years, who had not had mammograms in the prior 13 months. Practitioner communications and characteristics and women's subsequent mammography use were assessed through telephone interviews with participants. Controlling for pre-existing differences, communications and characteristics were entered in a hierarchical logistic regression on mammography use. Practitioner-specific communications predicted mammography use (e.g. endorsement, encouragement, and assistance with scheduling) as well as having internists as identified practitioners. Practitioners' mammography-specific communications can promote mammography among women who have not used it often in the past. Practitioners--especially those who are not internists--can examine whether their interactions are conducive to fostering mammography use.

Patient proactivity enhancing doctor-patient-family communication in cancer prevention and care among the aged

This paper presents a comprehensive conceptual model of health care communication involving three key health care partners: patients, physicians, and significant family members (health significant other, HSOs). A unique feature of this model is its focus on proactive roles played by elderly patients in information gathering and communication with health care partners regarding both cancer prevention and cancer care. We outline how proactive initiatives by health care consumers and involvement of their HSOs can enhance patient outcomes (satisfaction with physician, adherence to preventive and corrective practice recommendations, and quality of life). Finally, we also note primary antecedents of health care partner communication in terms of both medical care context and patient characteristics. We hope that this testable causal model will inform future research in the field of health communication.

The effect of comorbid illness on receipt of cancer screening by older people

OBJECTIVES

To identify associations between the type and number of diagnoses and receipt of screening for breast, cervical, and colorectal cancer by older people.

DESIGN

Sixth annual follow-up of a community-based survey with 4,162 participants aged 65 and older at baseline in 1986.

SETTING

Piedmont area of North Carolina.

PARTICIPANTS

Two thousand two hundred twenty-five subjects with a mean age of 79 who responded in 1992.

MEASUREMENTS

Self-reported receipt of clinical breast examination, mammography, Papanicolaou (Pap) smear, and fecal occult blood testing (FOBT) within the 2 years before the survey.

RESULTS

Hip fracture was associated with lower rates of mammography (odds ratio (OR) = 0.53, 95% confidence interval (CI) = 0.32-0.87) and cognitive impairment with lower rates of FOBT (OR = 0.71, 95% CI = 0.54-0.94). Hypertension was associated with higher rates of breast examination (OR = 1.56, 95% CI = 1.18-2.07), Pap smear (OR = 1.41, 95% CI = 1.09-1.83), and FOBT (OR = 1.37, 95% CI = 1.12-1.66) and a trend toward increasing rates of mammography (OR = 1.28, 95% CI = 0.98-1.69). The presence of three or more comorbid conditions was associated with an increased rate of mammography (OR = 1.35, 95% CI = 1.06-1.71), breast examination (OR = 1.46, 95% CI = 1.12-1.89), and Pap smear (OR = 1.31, 95% CI = 1.04-1.65).

CONCLUSIONS

With few exceptions, the presence of comorbid conditions is not associated with a decreased rate of receipt of screening. In fact, hypertension and the presence of a higher number of comorbid conditions are associated with a higher rate of receipt of cancer screening. This finding may be due to an increase in the frequency of office visits increasing the opportunity for cancer screening.

Prevention of cancer in the older person

Both primary and secondary cancer prevention may improve cancer control among older persons. Although chemoprevention of cancer is feasible, the agents currently used for chemoprevention have several complications. As a result, the use of these substances should be individualized based on risk-benefit ratio. It is reasonable to implement screening for cancer of the breast and of the large bowel in persons with a life expectancy of 5 years and longer. No definite recommendation may be issued at present related to screening for prostate, lung, and cervical cancer. Ongoing clinical trials may answer some of these questions.

A case for geriatric oncology

The increase in cancer incidence with increasing age is becoming more obvious and more important as the average age of the population increases. The close link between old age and cancer development is the result of three main factors: the substantial length of time required for carcinogenesis; the occurrence of age-related molecular changes that mimic carcinogenesis; and, changes in bodily environment that favour cancer progression, which is a consequence of increasing age. The clinical behaviour of common malignant diseases, eg, breast, ovarian, and lung cancers, lymphomas, and acute leukaemias, may change with age because of intrinsic variation of the neoplastic cells and the ability of the tumour host to support neoplastic growth. Therapeutic decisions should be based on an estimation of the patient's life expectancy, and risks and benefits should be weighted up accordingly. A comprehensive geriatric assessment of function, comorbidity, cognition, depression, social support, nutrition, and polypharmacy, would allow interventions to be tailored to individual needs. In developed countries, the numbers of older people who develop cancer are increasing and many questions remain unanswered. These issues include: the causes of the association of cancer and ageing; the age-related differences in cancer biology; the goals of cancer treatment in the aged; and the effectiveness of cancer prevention. We review the biological and clinical interactions of cancer and ageing and discuss the skills and knowledge necessary for caring for older patients.

Promoting fecal occult blood testing in rural African American women

PURPOSE

The purpose of this experimental study was to test the effectiveness of a multiphasic culturally relevant intervention, delivered over a 1-year period to increase the rates of participation in fecal occult blood testing (FOBT) at the initial screening opportunity and at the 1-year follow-up screening opportunity among rural African American women.

DESCRIPTION OF STUDY

The study used a pretest/post-test design among African American women who attended senior citizen centers in a rural southern state. The centers were randomly assigned to the cultural and self-empowerment group, who received the five-phased intervention, the modified cultural group, who received phase I of the intervention only, or the traditional group, who served as the control group. Data were collected at the initial and 1-year follow-up screenings. Hemoccult kits were distributed, collected, and analyzed at no cost to the participants. Data were analyzed using descriptive statistics, repeated measures, and longitudinal models for binary outcomes.

RESULTS

Women in the cultural and self-empowerment group had a significantly higher rate of participation in FOBT than did those in the modified cultural group and the traditional group. The modified cultural group had a significantly higher rate of participation in FOBT than the did the traditional group. Predictors of participation in FOBT were the women's family history of colorectal cancer and the average number of visits to their healthcare provider.

CLINICAL IMPLICATIONS

Colorectal cancer screening and diagnostic testing opportunities should be offered consistently to women who visit their provider for routine, nonemergent office visits. As successful interventions to increase colorectal cancer screening are introduced into community settings, these interventions also should be tested within physicians' offices and other community agencies.

Cancer screening in the elderly

A number of disease- and patient-specific factors need to be taken into account when cancer screening is considered in an older patient. They include the impact of aging on the cancer's biology and screening test performance, the patient's remaining years of life and candidacy for further diagnostic testing and available therapies, potential barriers to compliance with screening, and the patient's values and preferences about the screening.

A systems model of clinical preventive care: the case of breast cancer screening among older women. For the NCI Breast Cancer Screening Consortium

BACKGROUND

In older women covered by Medicare, relationships among physician recommendation, mammography in the past 2 years, and clinical breast examination (CBE) in the past year were systematically explored with a variety of predisposing, enabling, and situational factors identified in the Systems Model of Clinical Preventive Care.

METHODS

A population-based survey of women age 65 years and older was conducted in five National Cancer Institute's Breast Cancer Screening Consortium geographic areas. Analyses focused on women with a regular physician and site of care (n = 5318).

RESULTS

Physician recommendation and mammography use declined with women's increasing age and increased with income, education, and insurance. CBE and mammography increased with number of physicians and breast cancer family history; mammography use decreased with worsening health status. Recommendations were higher among physicians who were younger, female, and internists. Family practitioners were older and male; women who saw family practitioners reported characteristics associated with decreased screening-lower income, education, and insurance-and seeing only one physician.

CONCLUSIONS

Public policy and health system changes that create a uniform system of finance and service performance expectations may reduce the persistent discrepancy in physician recommendation and mammography use due to sociodemographics and physician specialty.

Racial differences in use of cancer prevention services among older Americans

CONTEXT

Racial differences in receipt of cancer prevention services may be related to poorer outcomes for minorities. Understanding reasons for such differences could help target appropriate interventions.

OBJECTIVES

To determine if racial differences exist in the use of cancer prevention services among older blacks and whites and to explore explanatory factors.

DESIGN

Sixth follow-up survey of probability sample, four-stage stratified household design with 4,162 at baseline in 1986-1987 and 2,846 surveyed in 1992-1993.

SETTING

The Piedmont area of North Carolina.

PARTICIPANTS

At time of follow-up survey in 1992-1993 there were 1,486 women and 726 men age >70 years, of whom 1,246 were black and 966 were white.

MEASUREMENTS

Self-reported use of Papanicolou (pap) testing, clinical breast examination, mammography, rectal examination, and fecal occult blood testing on a regular basis within the last two years.

RESULTS

Compared with older whites, older black persons are less likely to receive pap test (48.1% black vs 56.6% white, P < .001), clinical breast examination (64.6% black vs 69.2% white, P < .007), mammography (30.2% black vs 40.5% white, P < .001), rectal examination (50.2% black vs 62.4% white, P < .001), and fecal occult blood testing (37.5% black vs 46.2% white, P < .001). Effect of race on receipt of cancer prevention services was not significant when levels of education, income, and insurance coverage were considered.

CONCLUSION

Racial differences exist in the use of cancer prevention services among older Americans. However, these differences are related to educational, income, and insurance differences between blacks and whites.

Cancer and aging. An evolving panorama

This article illustrates how the nosology of cancer evolves with the patient's age. If the current trends are maintained, 70% of all neoplasms will occur in persons aged 65 years and over by the year 2020, leading to increased cancer-related morbidity among older persons. Cancer control in the older person involves chemoprevention, early diagnosis, and timely and effective treatment that entails both antineoplastic therapy and symptom management. These interventions must be individualized based on a multidimensional assessment that can predict life expectancy and treatment complications and that may evaluate the quality of life of the older person. This article suggests a number of interventions that may improve cancer control in the aged. Public education is needed to illustrate the benefits of health maintenance and early detection of cancer even among older individuals, to create realistic expectations, and to heighten awareness of early symptoms and signs of cancer. Professional education is needed to train students and practitioners in the evaluation and management of the older person. Of special interest is the current initiative of the Hartford Foundation offering combined fellowships in oncology and geriatrics and incorporating principles of geriatric medicine in medical specialty training. Prudent pharmacologic principles must be followed in managing older persons with cytotoxic chemotherapy. These principles include adjusting the dose according to the patient's renal function, using epoietin to maintain hemoglobin levels of 12 g/dL or more, and using hemopoietic growth factors in persons aged 70 years and older receiving cytotoxic chemotherapy of moderate toxicity (e.g., CHOP). To assure uniformity of data, a cooperative oncology group should formulate a geriatric package outlining a common plan for evaluating function and comorbidity. This article also suggests several important areas of research items: Molecular interactions of age and cancer Host-tumor interactions in the older tumor host Chemoprevention of cancer and aging Laboratory evaluation of aging Development of shorter forms of geriatric assessment Management of the frail cancer patients Clinical trials of tumor-specific issues.