Publications

Sankey diagram of agreement between dischareg summary, discharge instructions, and patient provided reasoning for chronic medication changes made during hospitalization.

INTRODUCTION: Women ≥70 years with low-risk breast cancer face nuanced therapy decisions. Using qualitative analysis, we aimed to determine how oncologists and patients integrate geriatric considerations into complex treatment conversations.

MATERIALS AND METHODS: We recruited women aged ≥70, newly diagnosed with clinical T1-2N0 hormone receptor-positive/HER2-negative disease between October 2020 and March 2023 from a large cancer center and audio-recorded and transcribed their consults with surgical, medical, and radiation oncologists. We identified geriatric issues included in conversational content and the dynamics of patient/oncologist communication. Data collection and analysis were simultaneously performed. We also assessed participant decision-making preferences, frailty, and life expectancy.

RESULTS: Of 48 eligible patients approached, 27 (56 %) participated with eight surgical oncologists, 17 with 11 medical oncologists, and four with three radiation oncologists (n = 48 consultations recorded). Fourteen patients (48 %) were ≥ 75 years, 23 were non-Hispanic White (76 %). Patients preferred to share (n = 15, 58 %) or make their own treatment decisions (n = 10, 39 %), rather than defer to the oncologist. Oncologists presented an explicit treatment choice in 16 conversations (35 %). Chronological age was discussed in 27 (56 %) conversations, comorbidities in 44 (92 %), and multimorbidity in two (4 %). Other geriatric considerations were discussed in the minority of conversations [physiologic age: 20 (42 %); function: 20 (42 %); quality-of-life: 5 (10 %); life expectancy: 5 (10 %); polypharmacy: 2 (4 %)].

DISCUSSION: Despite numerous treatment options, oncologists neither commonly offer older women with low-risk breast cancer explicit treatment choices, nor discuss geriatric issues besides comorbidity. Training oncologists in communication around geriatric issues may lead to more person-centered breast cancer care.

UNLABELLED: Background. The use of colorectal cancer (CRC) screening decision aids (DAs) increases patient knowledge and engagement in decision making. Thus, we aimed to implement a CRC DA in a Boston-area health system informed by the Theory of Change quality improvement framework. Methods. Following international standards, an interdisciplinary working group developed a 2-page CRC screening DA, readable on smartphones, for adults ages 45 to 75 y. Prior to DA implementation, we texted a study survey to 8,641 adults age 45 to 75 y seen in primary care at our health system (baseline). Between January 2022 and April 2023, we texted the DA to 21,522 patients due for CRC screening and scheduled with their primary care provider (PCP). In August 2022 and in May 2023 (follow-up), we texted a study survey to patients who had been texted the DA in prior months. We used linear regression to examine the DA's effects on shared decision-making (SDM) quality (using the 4-item SDM Process Scale, for which scores range from 0-4), knowledge (2 questions), and reported discussions with PCPs of screening modalities. Results. Of 30,163 texted study surveys, 1,692 (5.6%, 697 baseline and 995 follow-up) were completed; 77.1% of participants were non-Hispanic White and 45.3% were aged 60 to 75 y. Overall, 30.6% (n = 304) of follow-up survey respondents reported reviewing the DA. Compared with baseline participants, these patients reported higher SDM quality (SDM process scores = 2.5 v. 2.1, P < 0.001) and more knowledge about CRC screening and were more likely to have discussed stool-based testing with PCPs. Limitations. Low response rate with no sociodemographic data for nonresponders. Conclusions/Implications. Patients who read a CRC screening DA texted to them before primary care visits may experience improved SDM quality. However, a more intensive implementation strategy may be needed for more patients to read DAs.

HIGHLIGHTS: It is feasible for large health systems to automatize text messaging of colorectal cancer (CRC) screening decision aids (DAs) to patients due for CRC screening before a visit with their primary care practitioner.Patients who review a texted CRC screening DA report higher shared decision-making quality and knowledge about CRC screening.Use of CRC DAs may decrease screening via colonoscopy but not overall screening rates.A more intensive intervention than text messaging is likely needed to increase the number of patients who review a CRC screening DA.

OBJECTIVES: Emergency department (ED) visits offer opportunities for seriously ill patients to formulate future medical care goals, yet ED clinicians lack practical strategies for these conversations. ED GOAL, a behavioral intervention, engages seriously ill yet clinically stable older adults in the ED to address advance care planning (ACP) with their outpatient clinicians. In a randomized trial, goals-of-care documentation was significantly higher in the intervention group compared to controls after three (24.3% vs. 9.9%, p = 0.03) and 6 months (31.4% vs. 12.7%, p < 0.01). This study is a sub-analysis to learn about intervention arm participants' perceived benefits and obstacles of the intervention.

METHODS: We conducted semi-structured interviews between October 2022 and August 2024 (N = 52) with intervention-arm patients aged 50+ years at three hospitals in Boston, Massachusetts. Using rapid qualitative analyses, we identified themes in intervention-arm participants' comments to open-ended questions about the intervention's benefits and obstacles to continue ACP outside the ED.

RESULTS: Of 70 intervention-arm participants, 52 completed interviews, of which two were surrogates. ED GOAL motivated most patients to initiate ACP with outpatient clinicians and loved ones and improved the quality of conversations by clarifying patients' wishes and improving patient-clinician relations. Barriers to continuing ACP were the lack of clinician availability and patient/surrogate readiness. Those with clear care goals found the intervention less useful yet harmless.

CONCLUSIONS: The intervention provided participants with insights into actionable ACP steps. To address the lack of clinician availability, these conversations may be completed by non-physician clinicians or through non-personnel resources. Better tailored ACP interventions may improve patients' readiness.

TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT05209880.

OBJECTIVES: Guidelines recommend women consider their breast cancer risk and life expectancy when deciding on breast cancer screening (e.g., intervals, when to stop) and prevention medication. We previously developed a competing-risk model to predict 10-year breast cancer risk and non-breast cancer death in women > 55 years to support decision-making. Here, we aimed to develop a decision aid (DA) website incorporating our model's risk estimates.

METHODS: We designed the DA based on international standards using the free R package Shiny. We included a risk-assessment page, risk estimates, and decision support on breast cancer screening and prevention medications. We recruited national experts, Boston-area primary care practitioners (PCPs), and female patients > 55 years without breast cancer history to provide feedback on the DA via questionnaire or personal interview. We used thematic analysis to identify themes in participants' open-ended comments until reaching thematic saturation. Study questionnaires assessed DA helpfulness and ease-of-use.

RESULTS: Forty-five (53.6 %) of 84 eligible patients approached participated. Their mean age was 65.9 years (SD 7.9), 31 (68.9 %) were non-Hispanic White, and 31 (68.9 %) graduated college. Of 52 experts/PCPs contacted, 30 participated. Participants found the DA helpful (35/44 patients [79.5 %] and 28/29 [96.6 %] experts/PCPs) and easy-to-use (39/45 patients [86.7 %] and 28/29 PCPs/experts, [96.6 %]). They described the DA as "informative" and liked the "tailored-risk information." They suggested changes to simplify the DA and to better individualize the decision-support. We iteratively revised the website. We could not program some recommended changes using the free R application.

CONCLUSIONS: We developed an informative and easy-to-use breast cancer screening and prevention medication DA website (https://bcrisk55plus.shinyapps.io/risktool/) for women > 55 using free software. Next, we will program the website using HTML code and test its effects prospectively.

PRACTICE IMPLICATIONS: We anticipate that use of the DA will help women > 55 with breast cancer screening and prevention decisions.

OBJECTIVE: Breast cancer over-screening is common in older women. Messaging about breast cancer screening cessation may reduce over-screening but the broader informational environment often emphasizes screening continuation. We aimed to examine the effect of receiving consistent messages about breast cancer screening cessation versus conflicting messages (i.e., receiving messages about screening cessation and screening continuation from different sources).

METHODS: In a two-wave survey experiment with 3809 women 65 + years from a U.S. population-based online panel, we randomized participants to a) no messages, b) consistent messages promoting screening cessation, or c) conflicting messages - a message promoting screening continuation followed by a message promoting screening cessation.

RESULTS: The conflicting message group had significantly lower support for screening cessation in a hypothetical older woman (mean 3.87 [SD 2.00] on 7-point scale, 95 % CI 3.76-3.97) compared with the consistent message group (mean 4.17 [SD 1.99], 95 % CI 4.08-4.28), but was still significantly higher than the control group (mean 2.68 [SD 1.87], 95 % CI 2.54-2.82, p's < 0.001). Message effects on self-screening intentions were similar. Participants reported low rates of confusion, distrust or ambivalence.

CONCLUSIONS: Messaging about screening cessation can significantly increase older women's support for screening cessation, with low rates of negative reactions, even if there are competing messages on continued screening.

PRACTICE IMPLICATIONS: Messaging about screening cessation can be incorporated into clinical discussions or used in conjunction with other interventions aimed at reducing over-screening.

BACKGROUND: Limited access to primary care may disproportionately affect older adults, who often have greater chronic disease management and care coordination needs. However, little is known about the effect of having a primary care practitioner (PCP) on longevity in the aging population.

OBJECTIVE: To examine the association of having a usual source of primary care with mortality and life expectancy among US adults aged 65 and older.

DESIGN: Retrospective cohort study, using nationally representative data from the 2000 and 2005 cohorts of the National Health Interview Survey linked with National Death Index records through 2019.

PARTICIPANTS: All respondents aged 65 to 84 (n = 10,873, weighted n = 16,484,914).

INTERVENTIONS/EXPOSURES: Having a usual source of primary care.

MAIN MEASURES: Using a Cox proportional hazards model, we examined the association between exposure to primary care and 15-year mortality, adjusting for sociodemographic factors and respondent life expectancy (using a validated index). We also used this model to generate survival curves by exposure to primary care and computed median survival times for each group.

KEY RESULTS: Overall, 60.3% of respondents were female, 83.6% were non-Hispanic White, and 6.4% (n = 739, weighted n = 1,056,554) did not have a usual source of primary care. Use of primary care was associated with a lower 15-year mortality risk (aHR: 0.84, 95% CI: 0.72-0.98). Median survival time was also at least 2.1 years longer among those who used primary care (> 15 years) compared to those who did not (12.9 years).

CONCLUSIONS: We found that primary care use is associated with greater survival among older adults. As the population of adults aged 65 + is growing rapidly, investing in primary care is essential for the health of US older adults.

BACKGROUND: Medical cannabis consumption is rising, but limited evidence informs the safety and efficacy of cannabis use in cancer patients. A national survey of oncology trainees found that most fellows felt insufficiently informed to make clinical recommendations about cannabis.

AIM: In this secondary analysis, we aimed to measure how frequently trainees recommend in favor of cannabis and determine factors influencing this clinical practice.

METHODS: In this cross-sectional survey study for fellows enrolled in oncology training programs across the United States, an online survey assessing trainee practices regarding medical cannabis was sent to 155 oncology fellowship program directors from January - March 2021; who were asked to distribute it to their fellows. The primary outcome was the frequency with which oncology fellows recommended cannabis in the prior year.

RESULTS: Nationally, 40 programs from 25 states participated, with 189 of 462 trainees across these programs responding (40.9% response rate). 22% (95% CI: 16.3-29.0%) of participants reported recommending medical cannabis to > 5 patients in the past year. 24% (95% CI: 18.4-30.5%) of participants had prior training in medical cannabis. Regarding participant characteristics, only prior training in medical cannabis was significantly associated with recommending cannabis to > 5 patients (RR: 2.4; 95% CI: 1.4-4.2).

CONCLUSIONS: With increasing cannabis use among patients with cancer and given that a substantial number of oncology fellows recommend its use, it is crucial that fellowship training incorporate evidence-based curricula regarding medical cannabis use to guide informed decision-making between patients and their fellow providers.