Researchers have found that presenting older patients with personalized information regarding the benefits and harms of colorectal cancer screenings may reduce unnecessary screenings, according to a recent study published by Saini et al in JAMA Internal Medicine.
Background
Colorectal cancer screenings are currently recommended for individuals aged 45 to 75 who have an average risk of developing the disease. However, many patients may not realize that the benefits of screening for this type of cancer are not always the same for older individuals.
“While many [physicians] simply follow guideline recommendations for [colorectal] cancer screening in adults within this age range, this isn’t always the best approach,” explained co–lead study author Sameer Saini, MD, MS, a gastroenterologist at Michigan Medicine and the Lieutenant Colonel Charles S. Kettles VA Medical Center as well as a health services researcher at the University of Michigan Institute for Healthcare Policy and Innovation and the Ann Arbor VA Center for Clinical Management Research. “As individuals get older, they often acquire health problems that can lead to potential harm when coupled with endoscopy. While guidelines recommend a personalized approach to screening in average-risk individuals between [the] ages [of] 76 and 85, there are no such recommendations for older adults who are younger than…76 years—individuals who we commonly see in our clinics,” he added.
Study Methods and Results
In the randomized cluster trial, the researchers compared two different care strategies in 431 patients aged 70 to 75 at average risk of developing colorectal cancer—with the goal of determining the effects of personalizing care on the appropriate use of colorectal cancer screenings in older patients.
“Our study participants were due for a colorectal cancer screening and had no family history of colorectal cancer or personal history of colon polyps. Our control strategy was, in some ways, usual care. But we did change a few things at the health-system level, as well as at the physician level,” Dr. Saini noted.
The researchers made it possible for the physicians to stop screening patients within the control group without being penalized for doing so.
“Currently, physicians are penalized if they stop screening a patient before [the] age [of] 76, but our study allowed our participating physicians to make more personalized decisions about screening their patients based on individual factors and personal preferences,” Dr. Saini detailed.
Additionally, the researchers provided the physicians with education about how screening benefits change throughout a patient’s lifespan and how screening may potentially cause harm when the patients have competing comorbidities.
“In the intervention arm, physicians were also able to make more personalized decisions and were provided with education about screening benefits,” revealed co–lead study author Carmen Lewis, MD, MPH, Associate Professor of Internal Medicine at the University of Colorado. “But we also gave patients a personalized decision aid, which was a 30-page booklet with background information about screenings, as well as personalized information about screening benefits and harms based upon their age, screening history, sex, and whether they were healthy or sick at the time of the study,” she continued.
The researchers then combined the information into a personalized risk graph designed for easy interpretation—which included data on the benefits and harms of colorectal screenings derived from the MISCAN-Colon microsimulation model used by the U.S. Preventive Services Task Force to inform screening guidelines.
“However, the patients within the control arm simply received a simple screening informational booklet that was not personalized. We then looked at whether participants in each group received a screening order—be it a colonoscopy or a stool-based screening test—within 2 weeks of receiving this information. We also looked at whether they completed their recommended screening or not,” Dr. Lewis stated.
The researchers reported no statistically significant differences in the screening orders between the control arm and the intervention arm. “We had originally hypothesized there would be fewer screening orders in the intervention arm vs the control arm, because we thought the individuals receiving personalized information would eventually decide against screening. However, this wasn’t the case,” Dr. Lewis stressed.
The researchers conducted an interaction analysis to assess how the screening orders varied across the spectrum of screening benefits. “In particular, we analyzed how orders for screenings varied for patients who had low benefit vs high benefit for screening and…found that individuals within the control arm who were least likely to benefit from screenings got more screening orders than those in the intervention arm. In other words, the intervention reduced low-value screening orders. In contrast, we found that those in the control arm who were most likely to benefit got fewer screening orders than those in the intervention arm. Therefore, the intervention increased high-value screening orders,” Dr. Saini highlighted.
Conclusions
The researchers revealed the intervention was effective and the results from the control arm indicated that under usual care, colorectal cancer screenings were occurring in excess in low-benefit older patients and not enough in high-benefit older patients.
Although they found these results to be counterintuitive, the researchers emphasized they made sense given the benefits of screening were determined by the patients’ overall health as well as their screening history. For instance, the patients with health issues were more likely to visit their physicians, who may then order screenings—where those who have previously undergone screenings were more likely to be screened again.
“When we looked at screening use, it was about 13% lower in the intervention arm when compared [with] the control arm, as fewer intervention arm patients used screenings overall, likely reflecting a reduction in use of low-value care. Patients armed with personalized information were able to make good choices for themselves and, arguably, even better choices than what some [physicians] would have made for them,” Dr. Saini underscored.
Looking ahead, the researchers reiterated that screening rates do not vary by life expectancy in older patients, and acknowledging the potential of personalized care may be critical in this regard. “We saw consumers making sensible, health-care–aligned decisions when thinking about colorectal cancer prevention. [T]his approach could be brought to other preventive care services down the line. That gives me tremendous hope,” Dr. Saini concluded.
Disclosure: For full disclosures of the study authors, visit jamanetwork.com.
