Squeezing in the cancer screening talk

Regardless of best evidence and best intentions, working in a reminder, much less a discussion, about cancer screening during a typical brief patient visit can be challenging.

It's hard to say, “I think you have sinusitis, and by the way I noticed your last mammogram was a year and a half ago and I think it's time for another one,” said ACP Member Paul Mulhausen, MD, chief medical officer of Telligen, a health management firm based in West Des Moines, Iowa.

Experts say the best strategy is to redesign workflow to maximize use of team members and technology, with a focus on high-value care. Doing so will free up valuable physician-patient interaction time to most effectively apply cancer screening guidelines.

Dr. Mulhausen advocated a broader systems perspective. For example, a physician assistant might counsel the patient during the intake process about preventive tests while the physician focuses on the acute care issue.

“Imagine using some of that [intake] time to say, ‘I know it wasn't what you were planning to address today … but when was your last colonoscopy?’” he said. That type of conversation not only prompts accountability, he noted, but also action: in this case, perhaps a referral.

Focusing on high-value care then shifts the screening strategy from finding the most cases of cancer to balancing clinical benefits with harms such as false positives, pain, anxiety, overdiagnosis, and subsequent overtreatment, as well as costs and the optimal intensity of screening, said Timothy J. Wilt, MD, MPH, MACP.

Combined with best evidence and state-of-the-art methodology, that means some patients will get more screening and others will get less. “There's pressure from industry, colleagues, and even cancer survivors that more [screening] is better. But that is not always true,” said Dr. Wilt, core investigator and staff physician at the Minneapolis VA Center for Care Delivery and Outcomes Research, a professor of medicine at the University of Minnesota, and Chair of ACP's Clinical Guidelines Committee. Maximum detection strategies—however well intended—may not be in every patient's best interest, he said.

It also allows physicians to focus on individualizing care, Dr. Mulhausen said. “Remember, most of the time the things you're seeing in the office that are acute nobody dies from, and the things nobody is paying attention to can kill them,” he said. “I don't want to imply I have it figured out, but it's how I motivate myself to figure out how to address [cancer screening in office visits].”

Screening decisions

Instead of having to dig into data on changing cancer trends and recommendations, Dr. Mulhausen recommended using guidelines like ACP's to stay up-to-date.

Trends are changing quickly even for oncologists, said Nabil F. Saba, MD, FACP, professor of hematology, medical oncology, and otolaryngology, and director of the head and neck oncology program at Winship Cancer Institute at Emory University in Atlanta. A significant portion of lung cancer patients no longer have the traditional risk factors and are relatively younger, healthier nonsmokers, he said. There is also a rapid increase in esophageal cancer.

When guidelines don't agree, Dr. Mulhausen said he communicates the differences in a way that makes sense to his patients. His goals are to allay patients' fears and help them understand individual risk from the cancer as well as the screening procedures. “When a patient asks, ‘Why should I get a colonoscopy if there's no cancer in my family?’ I have to say it's not perfect. … At some level it boils down to does the patient trust your recommendation or not.”

Focus on the patient in front of you to avoid over- or under-screening even with guidelines in hand, said Stephen D. Persell, MD, MPH, FACP, director of the Center for Primary Care Innovation and associate professor of medicine in the division of general internal medicine and geriatrics at Northwestern University's Feinberg School of Medicine in Chicago. “Ask, ‘Who is this person? What are their comorbidities? What is right for them now?’” he advised.

Consider a 76-year-old who hikes and has a life expectancy of 20 years and a 74-year-old with heart failure who is on oxygen, said Louise C. Walter, MD, FACP, professor of medicine and chief of the division of geriatrics at the University of California, San Francisco. For the latter patient, getting a colonoscopy would be really risky and the harms would outweigh the benefits. But not for the former, she said.

She noted a time when she had to advocate with other physicians for a 93-year-old with dementia to not get a colonoscopy. “She'd been screened all her life and was not at high risk,” Dr. Walter said. “It would be more harmful than helpful to do it.”

When it comes to breast cancer screening, Dr. Mulhausen asks patients what they consider worse, not getting a mammogram, then finding a lump that had not been treated, or having a mammogram and being diagnosed with a lump that is biopsied and ends up not being cancer.

Practical tips

Make the most of your health system and staffing, recommended Jean Kutner, MD, MSPH, FACP. In her clinic, the medical assistants generate a list of cancer screening the patient is due for during check-in.

“All I have to do is click and sign if I put in that order,” said Dr. Kutner, chief medical officer of UCHealth at the University of Colorado Hospital in Aurora and professor of medicine at the University of Colorado School of Medicine. Or, the assistant may note that the patient is due for a specific screening and wants to talk about it.

Internists may benefit from having nurses on the front lines to listen to patients' symptoms and catch less obvious problems that may require cancer screening, Dr. Saba said.

Mitesh Patel, MD, MBA, MS, director of the Penn Medicine Nudge unit, a behavioral design team that coordinates research efforts between Penn's Center for Health Incentives and Behavioral Economics and innovation efforts at the Penn Medicine Center for Health Care Innovation, noted that having medical assistants triage screening allows doctors to spend less time scrolling through alerts and more time talking to patients.

In addition, having a more comprehensive strategy leveraging staff and technology can help overcome decision fatigue, said Dr. Patel, author of a May 10 JAMA Network Open study finding that fewer screening tests were ordered at the end of shifts.

“We know doctors and patients naturally run late, so scheduling is part of [a cancer screening strategy],” said Dr. Patel, who is also a physician at the Philadelphia VA Medical Center. “We have evidence, and practitioners should use that to improve cancer screening rates. We have to figure out ... how to set the default to have cancer screening discussed and/or ordered and allow clinicians and patients to opt out when necessary. The emphasis should be on how setting up the defaults can lead to higher rates of screening.”

Other tips include the following:

• Make use of the “Welcome to Medicare” preventive visit. This is a good time to discuss cancer screening with beneficiaries you will see often for acute problems when they are feeling well. It's also a way to target otherwise healthy patients who might not visit the doctor often.
• Take advantage of other patient encounters. Address screening when patients visit for chronic conditions and/or remind patients when they come to get their flu shot.
• Set aside time for prevention. For other patients, especially those with a lot of medical complexity, set aside time once a year to discuss cancer screening.
• Mention it now, but discuss it later. “If the patient comes in with knee pain, I can say, ‘Hey it looks like you're due for some annual screenings. Why don't I go ahead and order them now and you can get them done and we can talk about them when I see you next?” said Dr. Kutner.
• Deliver reminders to patients directly. Use mail, email, or patient portals to let patients know they are due for screening services.
• Be patient-friendly. Be sure patient reminders are in the patients' language. Also, some clinics have found they can increase screening rates by partnering with patient navigators who are members of patients' communities or share similar backgrounds.
• Cultivate your office culture. Make sure everyone on your staff feels responsible for having an impact on patients' health.
• Leverage technology. Take advantage of what's available, whether it's EHR notifications that pop up on the screen when you see a patient, health coaching trainers who can prompt decision-making for particular patients, or scheduling through an app for a patient who doesn't need a shared-decision making discussion with his or her physician.
• But don't rely on technology for everything. If it's the patient's first time getting a particular screening, see him or her in person to discuss eligibility and questions, said Dr. Patel.

When the patient disagrees

Explore why patients decline to have a screening test. They might see no reason to do something if they don't feel unwell, question its value, or say it disrupts their life, Dr. Mulhausen said. Others cite cost concerns. “A lot of time the conversation becomes [whether or not] insurance covers it,” he said.

For those who decline because of fear, Dr. Wilt recommended putting the screening in perspective. “Cancer screening is a strategy and a pathway, not just a single test,” he said.

If a patient disagrees with his cancer screening recommendation, Dr. Mulhausen works on keeping the door open and says, ‘Here's the paperwork, and I'll make a phone call for you. If you change your mind, you can go do it.”

He also makes a note to bring up the topic as part of the problem list at the next office visit. For patients who repeatedly decline a recommended screening, Dr. Kutner explains, “It's my obligation to bring it up again just to let you know it's my recommendation.”

Patients may unexpectedly change their minds, Dr. Persell said. He had a patient who repeatedly declined a colonoscopy but said he was ready after a friend of his was diagnosed with colon cancer. “When patients are motivated, we remove barriers,” he said.

On the other hand, some patients think cancer screening has no downsides and want it even when it's not recommended, said Dr. Walter. For those patients, Dr. Wilt suggested discussing whether tests meet the high-value bar in their specific situations. “I try to talk about the science and … [the patient's] best interest,” he said.

For a patient asking for an unnecessary prostate screening test, for example, he would say, “Let's focus on whether the screening test will help you live better or longer. The answer, unfortunately, is probably not. But if you notice anything, sudden changes in urine flow or blood in the urine, for example, come and talk to me.”

Dr. Persell recommended saying, “Let's not worry about the things we can't control. Instead, having a healthy lifestyle and avoiding tobacco can reduce your risk of cancer overall.”

Elderly patients may want to continue screening despite recommendations to the contrary because they overestimate the benefits, have low awareness of the potential harms, and are reluctant to stop something familiar, Dr. Walter noted in a recent article published in the August Journal of General Internal Medicine.

When Dr. Mulhausen told an 86-year-old man he didn't need to screen for prostate cancer, for example, the patient responded, “So you're just going to give up on me?” Dr. Mulhausen said he embraced his “do no harm” role during the discussion and talked about finding the best outcomes for the patient. In this case, he explained, the upsides of the interventions were mitigated by the downsides.

Experts gave other examples of how they talk and work with elderly patients about this sensitive issue. Dr. Persell said he tells patients, “This may be a reasonable thing for you to do at age 60, but probably not at age 75 if you screen negative before that. We're doing what's right for you now, but that will change over time.”

Dr. Wilt says, “Your screen has been normal for years. It's unlikely you will benefit and more likely you will be harmed. Let's focus on other areas more likely to help you live longer and better. Not this test. I recommend against it.”

When a patient insists on a test, however, Dr. Wilt tells him or her, “If all looks good on [this test], the great news is I don't think we need to do further testing down the road.”

Explaining risks and benefits of screening to patients will usually pay off, Dr. Kutner said. “Sometimes I get, ‘Well, my mom lived until she was 105.’ But [most] people in their late 70s, 80s, and 90s have thought about their own mortality,” she said.