Attitudes Towards Continuing Cancer Screening Later in Life
This study explored attitudes towards age-based stoppage screening policies, information preferences and intentions to request screening after the end of the routine invitations among older adults in England. Both men and women were surveyed, extending previous research that has largely focused on mammography.
Most respondents held positive attitudes towards continuing screening after the end of the call–recall programmes; consistent with a previous study showing that the majority of British women aged over 70 would like to continue receiving automatic invitations for mammography screening after the end of the routine programme regardless of health status. These findings are in line with evidence of high general public enthusiasm for cancer screening.
Interestingly however, only just over a quarter of respondents (27%) strongly intended to carry on with screening. This contrasts with a US study in which most adults (72%) aged 70 or more reported that they planned to continue CRC screening throughout their lives. Nevertheless the number of people intending to carry on with screening in our sample is still considerably greater than the current opt-in rates in England. It is possible that individuals change their minds once they get older, but perhaps more likely that they forget to arrange screening or forget how to request it when they stop being invited automatically. However, it is also plausible that as the cohort surveyed here reaches the age of routine screening invitation stoppage, they may want to know more about opt-in opportunities. Indeed, a third of respondents reported that they would be 'quite likely' to carry on with screening. With increasing emphasis on improving information and communication about screening, national programmes may need to review the information they supply on opt-in policies.
It is also possible that the relatively low levels of intention to continue screening may in part reflect some level of understanding that the benefits of screening at older ages are likely to be moderated by health status and life expectancy. An individual's ability to tolerate the required treatment, and implications for future quality of life, complicate the decision-making process. The decision whether or not to continue screening for a specific cancer may require support from health professionals in primary care to enable a more personalised or 'negotiated' recommendation. We know that the UK public value a recommendation from the NHS to attend screening, but GPs may be called on to have more direct involvement in screening decisions in older adults. As the views of the GP can influence patient choices, either explicitly through endorsement, or through more subtle mechanisms, there is a need for guidance for GPs and other healthcare providers on discussing screening options with their patients who are reaching the upper age-limit of screening programmes.
The population sampling frame and large sample size made it possible to examine demographic as well as attitudinal predictors in this under-investigated area. In common with other surveys, respondents may have been more positively disposed towards screening than the general population; however, the presentation of this survey made it clear it was covering a range of issues, so specific attitudes to screening were unlikely to have biased participation. Confidence in the sample representativeness is increased by the finding that self-reported CRC screening participation among eligible respondents (54%) was in line with uptake rates in England, although mammography screening rates were higher than the national coverage figure of 73%. In terms of interpreting people's responses, they were not provided with information on any age-specific advantages and disadvantages of screening, which may have limited their ability to make informed responses. Finally, while this survey focused on the potential contribution of primary care, other healthcare professionals especially geriatricians may also play an important role in facilitating decisions about cancer screening and treatment in later life.
Discussion
This study explored attitudes towards age-based stoppage screening policies, information preferences and intentions to request screening after the end of the routine invitations among older adults in England. Both men and women were surveyed, extending previous research that has largely focused on mammography.
Most respondents held positive attitudes towards continuing screening after the end of the call–recall programmes; consistent with a previous study showing that the majority of British women aged over 70 would like to continue receiving automatic invitations for mammography screening after the end of the routine programme regardless of health status. These findings are in line with evidence of high general public enthusiasm for cancer screening.
Interestingly however, only just over a quarter of respondents (27%) strongly intended to carry on with screening. This contrasts with a US study in which most adults (72%) aged 70 or more reported that they planned to continue CRC screening throughout their lives. Nevertheless the number of people intending to carry on with screening in our sample is still considerably greater than the current opt-in rates in England. It is possible that individuals change their minds once they get older, but perhaps more likely that they forget to arrange screening or forget how to request it when they stop being invited automatically. However, it is also plausible that as the cohort surveyed here reaches the age of routine screening invitation stoppage, they may want to know more about opt-in opportunities. Indeed, a third of respondents reported that they would be 'quite likely' to carry on with screening. With increasing emphasis on improving information and communication about screening, national programmes may need to review the information they supply on opt-in policies.
It is also possible that the relatively low levels of intention to continue screening may in part reflect some level of understanding that the benefits of screening at older ages are likely to be moderated by health status and life expectancy. An individual's ability to tolerate the required treatment, and implications for future quality of life, complicate the decision-making process. The decision whether or not to continue screening for a specific cancer may require support from health professionals in primary care to enable a more personalised or 'negotiated' recommendation. We know that the UK public value a recommendation from the NHS to attend screening, but GPs may be called on to have more direct involvement in screening decisions in older adults. As the views of the GP can influence patient choices, either explicitly through endorsement, or through more subtle mechanisms, there is a need for guidance for GPs and other healthcare providers on discussing screening options with their patients who are reaching the upper age-limit of screening programmes.
Strengths and Limitations
The population sampling frame and large sample size made it possible to examine demographic as well as attitudinal predictors in this under-investigated area. In common with other surveys, respondents may have been more positively disposed towards screening than the general population; however, the presentation of this survey made it clear it was covering a range of issues, so specific attitudes to screening were unlikely to have biased participation. Confidence in the sample representativeness is increased by the finding that self-reported CRC screening participation among eligible respondents (54%) was in line with uptake rates in England, although mammography screening rates were higher than the national coverage figure of 73%. In terms of interpreting people's responses, they were not provided with information on any age-specific advantages and disadvantages of screening, which may have limited their ability to make informed responses. Finally, while this survey focused on the potential contribution of primary care, other healthcare professionals especially geriatricians may also play an important role in facilitating decisions about cancer screening and treatment in later life.