CRC Screening Decision Aid May Align Preferences With Benefits in Older Adults

While a decision aid on preferences for colorectal cancer (CRC) screening aimed at older adults appeared to help improve knowledge, findings from a secondary analysis of a randomized trial did not show statistically significant differences in patient preferences between patients in varying states of health (poor, intermediate, or good).

Among participants with an intermediate health state, 44.7% of those in the intervention group preferred screening compared with 54.8% of those in the control group (P=0.22), and for those in a poor health state, these proportions were 38.7% versus 54.1% (P=0.08), reported Carmen L. Lewis, MD, MPH, of the University of Colorado School of Medicine in Aurora and colleagues.

The proportion in good health who preferred screening was similar in both groups (59.5% vs 61.3%, respectively, P=0.82), they noted in JAMA Network Open.

“Our study is important because it demonstrates that, among a sample of older adults with a broad range of health states, when informed and faced with the screening decision, older adults’ preferences may differ based on health state and life expectancy,” Lewis and team wrote.

“The key takeaway is that the CRC decision aid for older adults appears to align patient preferences with their potential to benefit from screening — people in poor health are less likely to prefer screening than those who are in better health,” Lewis told MedPage Today. “That said, there is a big caveat. Although this was a prespecified secondary analysis, the study was not powered on this outcome and the results are not statistically significant.”

When looking at participant questionnaires, the decision-aid group scored significantly higher on questions involving CRC knowledge compared with the control group (mean 4.1 vs 2.3). Interestingly, the differences in CRC knowledge scores between groups were similar across health states, with no significant interaction effect.

The intervention group also had a lower mean score on the values clarity subscale, indicating greater clarity (mean 2.33 vs 26.9), which was also similar across the different states of health.

“We performed this analysis to determine whether a patient decision aid that informs patients about the potential harms would decrease preferences in favor of CRC screening among older adults who are unlikely to benefit from it,” Lewis and team wrote.

“We found that the targeted decision aid for CRC screening in older adults improved knowledge and helped clarify their values before an appointment with their clinician, suggesting that participants understood the message in the decision aid that screening may not be beneficial for all older adults and were better prepared to make a decision,” they continued.

Overall, more participants in the intervention group were undecided on their screening preference, regardless of their state of health, “suggesting the information may have had an effect on patient preference,” they added.

The U.S. Preventive Services Task Force has recommended individualized decision making for CRC screening in adults ages 76 to 84 since 2008, specifically advising “a consideration of health state and patient preferences,” Lewis and colleagues noted.

The benefits of early polyp detection are often seen 5 to 10 years after patients undergo CRC screening, since CRC is a slow-growing cancer. For older individuals in poor health with life expectancies below 5 years, the risks, including perforation, bleeding, or death, may outweigh the benefits of CRC screening; however, for those in good health, the benefits of screening likely outweigh the risks.

For this study, Lewis and colleagues included 424 participants ages 70 to 84 who were not up to date on CRC screening from 14 community-based primary care practices. Mean age was 76.8, 58.5% were women, and 78.5% were white.

The participants had been randomized 1:1 to the decision aid intervention or a control group from March 2012 through February 2015. The decision aid, “Making a Decision About Colon Cancer Screening,” describes stool-based testing, colonoscopy, the requirement of colonoscopy for all positive stool results, and the harms of screening, in accordance with the age and sex of participants, based on international standards for decision aid development.

The control group received a driving decision tool that was developed by the American Automobile Association Foundation for Traffic Safety, called “Drivers 65 Plus: Check Your Performance.”

An adaptation of the Charlson Comorbidity Index combined with age was used to assess participants’ health state.

Of the participants, 149 were in good health, 150 were in intermediate health, and 124 were in poor health.

Lewis and team acknowledged that the analysis lacked statistical power to evaluate differences in screening preferences. Findings are mostly generalizable to older, well-educated, white individuals. The study was also conducted in 2013, prior to the widespread use of fecal immunochemical testing.