Publications

OBJECTIVE: Messaging about breast cancer screening cessation may reduce over-screening by raising awareness of the harms of screening, but in a background of strongly positive beliefs about screening among the public, such messaging may be perceived negatively. We aimed to assess whether older women perceived it to be ethically appropriate for clinicians to share a message that encourages breast cancer screening cessation.

METHODS: As part of a large national online survey experiment with women 65+ years, we presented a message (hereafter referred to as primary message) describing the rationales for stopping breast cancer screening (e.g., guideline recommendation, harms of screening) and assessed how ethical women thought it would be for doctors to share this information with patients. We assessed open-ended reactions. We also tested two variations of the primary message with different wordings of the recommendation to consider stopping screening.

RESULTS: Of 683 participants, 75.9 % agreed that the primary message is ethically appropriate for doctors to share with patients., 13.2 % neither agree or disagree, and 10.9 % disagreed. Themes in open-ended responses suggested that the difference in participant response was partly attributed to whether participants perceived the message as informative or persuasive. Comparing across message variations, messages with stronger recommendations to stop screening were perceived to be less ethically appropriate than the primary message.

CONCLUSIONS: Most older women perceived that it was ethically appropriate for doctors to share messages aimed at reducing breast cancer over-screening with patients.

PRACTICE IMPLICATIONS: Interventions should be developed to deliver messages to reduce over-screening among older women in practice settings, with evaluations to monitor their response.

BACKGROUND: Treatment burden refers to the patient-perceived effort of managing health and health care, which impacts quality of life and engagement in care. International studies of treatment burden have found high rates of treatment burden among adults with chronic conditions. However, the scope of treatment burden among US older adults is unknown. We described the prevalence of and characteristics associated with treatment burden among US adults age ≥ 50 years.

METHODS: We performed a cross-sectional study of 1795 adult respondents to the 2022 Health and Retirement Study (HRS) Treatment Burden Questionnaire (TBQ), a random sub-sample from a nationally-representative panel study of community-dwelling US adults age ≥ 50 years. The primary outcome was total treatment burden score (15 items each scored 0-10, total 0-150; threshold ≥ 59 for high burden). We used multivariable linear regression to examine the association between log-transformed total treatment burden score and sociodemographic, health, and functional status characteristics.

RESULTS: The mean age of 1795 respondents was 68.5 (SD 8.5) years, 56% were female, and the median TBQ score was 12 (IQR 5-25). Overall, 87% (n = 1550) reported treatment burden (TBQ score ≥ 1); 5% reported high burden. The most common sources of treatment burden were reminders of health problems (61%) and administrative (53%) and financial burdens (46%). Adults age ≥ 65 years were both less likely to report treatment burden and reported lower burden than adults age 50-64 years. Factors associated with greater burden included a higher number of chronic conditions, vision or hearing impairment, ADL/IADL difficulty, and mobility difficulty.

CONCLUSIONS: Most US adults age ≥ 50 years report treatment burden, though there is wide variation in the degree of burden reported. Reducing treatment burden within the US may require reducing administrative and financial burdens of care and addressing factors that impair patient capacity to manage health and health care.

BACKGROUND: Oncology providers often lack the confidence to make clinical recommendations about medical cannabis (MC). This study aimed to develop and evaluate the feasibility of implementing an educational curriculum on the use of MC in patient care for oncology trainees.

METHODS: A multidisciplinary team designed an educational curriculum for MC use in oncology. The curriculum was piloted as a 1-hour interactive webinar across 8 United States-based hematology/oncology fellowship programs between 2022 and 2023. Incentivized surveys measuring feasibility outcomes, including cultural attitudes/norms, acceptability, compatibility, and self-efficacy (a composite index of self-confidence in discussing MC efficacy, risks, modes of use, and role in symptom management), were distributed before, immediately after, and 12 weeks post-webinar.

RESULTS: Of 103 trainees, 75 (72.8%) completed the pretraining survey and 66 (64.1%) completed the posttraining survey. Most respondents believed discussions about the role of MC in symptom management were valuable (n=56; 74.7%), though few (14.7%) believed trainees were expected to engage in such discussions. Most participants rated the curriculum as helpful (92.4%), beneficial for oncology trainees (84.8%), and likely to be recommended to colleagues (87.9%). Post-webinar, 78.8% of participants reported an increased likelihood of initiating discussions with patients regarding MC. There were significant improvements in the composite self-confidence index from pre- to post-webinar (2.7% vs 65.2%; P<.001), which persisted in the follow-up surveys (n=36; response rate, 34.9%).

CONCLUSIONS: This multisite study demonstrates the feasibility of implementing a novel curriculum focused on MC for oncology trainees. These findings can guide the design of a prospective, multi-institutional study to evaluate knowledge expansion, retention, and behavioral changes resulting from the intervention.

BackgroundAdvance care planning (ACP) helps older adults make end-of-life medical decisions. While ACP discussions are associated with improved patient outcomes, overall engagement remains low in the emergency department (ED).ObjectivesThis study assessed ACP engagement in older ED patients.MethodsWe conducted a questionnaire study among adults ≥65 in a Boston ED (July-Oct 2023). Our primary outcome was ACP Engagement as measured by a validated 9-item instrument with three ACP self- efficacy and six ACP readiness questions. Secondary outcomes included participants' preferences for learning about five ACP topics in the ED-medical decision makers, what matters most, leeway and flexibility for decision makers, sharing wishes, and asking questions)-as well as their favored learning formats (eg, pamphlets, videos, clinician conversations). Each was rated on a 5-point Likert scale. We examined the relationship between ACP engagement and existing electronic health record (EHR) documentation.ResultsNinety-nine older adults participated (mean age 75.5; 53.5% women). On the 9-item ACP Engagement Survey, participants reported high overall scores with a mean of 4.1 (95% CI: 4.0-4.2). Among ACP readiness topics, 80 (81.6%) named a decision-maker; 37 (40.2%) discussed end-of-life wishes with doctors. Participants preferred ED team conversations. Among the 51 participants who reported having signed paperwork regarding end-of-life wishes, only 7 (13.7%) had forms documented in the EHR.ConclusionsAmong older adults in a large Boston-based ED, ACP engagement was high, but few patients had documentation of end-of-life wishes available in the EHR. Findings highlight the need for better ACP documentation in EDs.

PURPOSE: To inform decision making around mammography-screening frequency and cessation, we previously used Fine-Gray competing-risk regression to develop and validate a model to estimate older women's 10-year risk of breast cancer and their competing risk of non-breast cancer (non-BC) death. Here, we aimed to understand the amount of incident breast cancer and non-BC death risk explained by our model among women ≥ 65y.

METHODS: We included women ≥ 65y who completed the 2004 Nurses' Health Study questionnaire (NHS, n = 59,662) or who participated in the Women's Health Initiative-Extension Study (WHI-ES, n = 82,528). We calculated our model's full and risk factor-specific population attributable risk (PAR%) for incident breast cancer and non-BC death.

RESULTS: Mean age of the NHS participants was 73.5y (SD 5.2); 3.1% were diagnosed with breast cancer and 26.1% experienced non-BC death within 10 years. Mean age of WHI-ES participants was 73.6y (SD 5.4); 4.2% were diagnosed with breast cancer and 17.7% experienced non-BC death within 10 years. The full-model PAR% for breast cancer was 58.8% (22.7-80.6) in NHS and 54.8% (24.8-75.2%) in WHI-ES. Modifiable risk factors explained approximately 1/3 of breast cancer risk; BMI ≥ 30 had a PAR% of 6.5% (3.1-9.9%) in NHS and 12.2% (8.5-16.0%) in WHI-ES. For non-BC death, the full-model PAR% was 94.2% (91.4-96.1%) in NHS and 86.2% (80.9-90.0%) in WHI-ES.

CONCLUSIONS: Our competing-risk model explained the majority of breast cancers and non-BC deaths in women ≥ 65y, and we identified risk factors (e.g., elevated BMI) that may be targeted to reduce the burden of breast cancer in older women.

IMPORTANCE: Conversations between seriously ill patients and clinicians about values and goals (ie, serious illness conversations [SICs]) can lead to patient-centered care toward the end of life. However, many patients have not had SICs when arriving in the emergency department (ED) and are at risk of receiving undesired care.

OBJECTIVE: To determine the effect of an ED-based, multimodal SIC intervention (known as ED GOAL) compared with usual care on patient-reported engagement in advance care planning (ACP) and clinician-documented SICs after leaving the ED.

DESIGN, SETTING, AND PARTICIPANTS: This 2-armed, 1:1, parallel-design randomized clinical trial was conducted at 3 participating EDs (2 academic medical centers and 1 community hospital) in Boston, Massachusetts, within a single health system between March 1, 2022, and July 1, 2024, with a follow-up duration of 6 months. Eligible participants were English-speaking adults 50 years or older with serious illnesses, including mild cognitive impairment or mild dementia, along with their caregivers. For patients with moderate to severe dementia, caregivers were the primary participants in the study. Patients with documented goals for medical care or physician orders in the last 3 months in medical records or deemed clinically inappropriate by the treating ED team were excluded.

INTERVENTION: SIC-trained research nurses conducted (1) a motivational interview about SICs, (2) a structured SIC, and (3) communication priming for the patients and their primary clinicians to reinitiate SICs on a tablet computer in the ED or within 1 week after leaving the ED.

MAIN OUTCOMES AND MEASURES: The primary outcome was a validated survey of patient-reported engagement in ACP at 1 month, with total possible scores ranging from 1 to 5, with higher scores indicating more engagement. Secondary outcomes included clinician documentation of end-of-life values and preferences in the medical record and completed advance directives.

RESULTS: A total of 141 patients (mean [SD] age, 66.7 [9.2] years; 73 [51.8%] female), predominantly diagnosed with metastatic cancer (85 [60.3%]), were enrolled and randomized to the intervention (n = 70) or usual care (n = 71). At 1 month, no difference was observed in patient-reported engagement in ACP (mean [SD] score, 3.32 [1.28] for control vs 3.37 [1.07] for intervention; maximum possible score, 5.00; P = .58), yet 12 patients in the intervention group (17.1%) discussed care preferences with their physicians compared with 5 (7.0%) control group patients (P = .07). Medical record documentation of end-of-life values and goals was significantly higher in the intervention group at 3 months (17 [24.3%] vs 7 [9.9%]; P = .03) and 6 months (22 [31.4%] vs 9 [12.7%]; P =  .008).

CONCLUSIONS AND RELEVANCE: In this randomized clinical trial of seriously ill older adults in the ED, while a nurse-led SIC intervention did not significantly improve patient-reported engagement in ACP, it did increase clinician-documented SICs in the medical records. ED visits may serve as a critical access point to enhance SICs for seriously ill yet clinically stable older adults.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05209880.