Perceived Barriers Among Clinicians and Older Adults Aged 65 and Older Regarding Use of Life Expectancy to Inform Cancer Screening: A Narrative Review and Comparison.

While cancer screening guidelines increasingly recommend incorporating life expectancy estimates to inform screening decisions for older adults, little is known about how this happens in practice. This review summarizes current knowledge about primary care clinician and older adult (65+) perspectives about use of life expectancy to guide cancer screening decisions. Clinicians report operational barriers, uncertainty, and hesitation around use of life expectancy in screening decisions. They recognize it may help them more accurately weigh benefits and harms but are unsure how to estimate life expectancy for individual patients. Older adults face conceptual barriers and are generally unconvinced of the benefits of considering their life expectancy when making screening decisions. Life expectancy will always be a difficult topic for clinicians and patients, but there are advantages to incorporating it in cancer screening decisions. We highlight key takeaways from both clinician and older adult perspectives to guide future research.

"It's something I'll do until I die": A qualitative examination into why older women in the U.S. continue screening mammography.

BACKGROUND: Professional guidelines in the U.S. do not recommend routine screening mammography for women ≥75 years with limited life expectancy and/or poor health. Yet, routine mammography remains widely used in older women. We examined older women's experiences, beliefs, and opinions about screening mammography in relation to aging and health. METHODS: We performed thematic analysis of transcribed semi-structured interviews with 19 women who had a recent screening visit at a mammography clinic in New York City (average age: 75 years, 63% Hispanic, 53% ≤high school education). RESULTS: Three main themes emerged: (1) older women typically perceive mammograms as a positive, beneficial, and routine component of care; (2) participation in routine mammography is reinforced by factors at interpersonal, provider, and healthcare system levels; and (3) older women do not endorse discontinuation of screening mammography due to advancing age or poor health, but some may be receptive to reducing screening frequency. Only a few older women reported having discussed mammography cessation or the potential harms of screening with their providers. A few women reported they would insist on receiving mammography even without a provider recommendation. CONCLUSIONS: Older women's positive experiences and views, as well as multilevel and frequently automated cues toward mammography are important drivers of routine screening in older women. These findings suggest a need for synergistic patient, provider, and system level strategies to reduce mammography overuse in older women.

Patient perspectives on treatment decision-making under clinical uncertainty: chemotherapy treatment decisions among stage II colon cancer patients.

The decision to use adjuvant chemotherapy (ACT) after surgical resection for stage II colon cancer remains an area of clinical uncertainty. Many patients diagnosed with stage II colon cancer receive ACT, despite inconclusive evidence of long-term clinical benefit. This study investigates patient experiences and perceptions of treatment decision-making and shared decision making (SDM) for ACT among patients diagnosed with stage II colon cancer. Stage II colon cancer patients engaged in treatment or follow-up care aged >18 years were recruited from two large NYC health systems. Patients participated in 30-60-min semi-structured interviews. All interviews were transcribed, translated, coded, and analyzed using a thematic analysis approach. We interviewed 31 patients, of which 42% received ACT. Overall, patient perspectives indicate provider inconsistency in communicating ACT harms, benefits, and uncertainties, and poor elicitation of patient preferences and values. Patients reported varying perceptions and understanding of personal risk and clinical benefits of ACT. For many patients, receiving a clear treatment recommendation from the provider limited their participation in the decision-making process, whether it aligned with their decisional support preferences or not. Findings advance understanding of perceived roles and preferences of patients in SDM processes for cancer treatment under heightened clinical uncertainty, and indicate a notable gap in understanding for decisions made using SDM models in the context of clinical uncertainty. Educational and communication strategies and training are needed to support providers in communicating uncertainty, risk, treatment options, and implementing clinical guidelines to support patient awareness and informed decisions.

Trust and Mistrust in Shaping Adaptation and De-Implementation in the Context of Changing Screening Guidelines.

Objective: To understand barriers and facilitators to the adaptation of programs reflecting changing scientific guidelines for breast/cervical cancer screening, including factors influencing the de-implementation of messaging, program components, or screening practices no longer recommended due to new scientific evidence. Setting: National sample of NWP sites from across the United States. Design and Methods: We conducted a convergent mixed-methods design in partnership with The National Witness Project (NWP), a nationally implemented evidence-based lay health advisor (LHA) program for breast/cervical cancer screening among African American (AA) women. Surveys were conducted among 201 project directors (PDs) and LHAs representing 14 NWP sites; in-depth interviews were conducted among 14 PDs to provide context to findings. Survey data and qualitative interviews were collected concurrently from January 2019-January 2020. Results: Trust and mistrust were important themes that arose in quantitative and qualitative data. Common concerns about adapting to new guidelines included: 1) perceptions that new guidelines misalign with the personal values and beliefs of AA women; 2) mistrust of guidelines, providers, medical organizations; 3) confusion about inconsistent guidelines and concern they are based on studies that don't reflect the experience of AA women (who experience more aggressive tumors at younger ages); and 4) belief that breast self-exam (BSE) is an empowerment tool for AA women and should be included to promote awareness, given many women discovered lumps/cancer through BSE. Conclusion: Findings highlight that trust and mistrust are important but understudied social determinants of health among AAs that should be considered in implementation science as they: 1) have critical implications for shaping health inequities; and 2) help explain and contextualize why new screening guidelines may not be fully embraced in the AA community.

What Is Dissemination and Implementation Science?: An Introduction and Opportunities to Advance Behavioral Medicine and Public Health Globally.

There has been a well-documented gap between research (e.g., evidence-based programs, interventions, practices, policies, guidelines) and practice (e.g., what is routinely delivered in real-world community and clinical settings). Dissemination and implementation (D&I) science has emerged to address this research-to-practice gap and accelerate the speed with which translation and real-world uptake and impact occur. In recent years, there has been tremendous development in the field and a growing global interest, but much of the introductory literature has been U.S.-centric. This piece provides an introduction to D&I science and summarizes key concepts and progress of the field for a global audience, provides two case studies that highlight examples of D&I research globally, and identifies opportunities and innovations for advancing the field of D&I research globally.

An orientation for new researchers to key domains, processes, and resources in implementation science.

The growth of dissemination and implementation (D&I) research over the last decade has produced a wealth of theories, frameworks, methods, strategies, and resources to inform the translation of evidence into wider practice. This article seeks to frame and orient researchers from the behavioral sciences to the rapidly growing interdisciplinary field of D&I science. We describe five domains across D&I research and practice: context assessment and intervention selection, dissemination, adaptation, implementation, and sustainability. We also discuss evaluation and communication as critical processes to drive ongoing learning and improvement across the five domains. In each section, we include widely cited literature and resources that readers may use to orient themselves to the field, and identify areas that they may want to explore further. This article organizes major areas of D&I science focusing on key definitions, approaches, and commonly used resources. It provides an introduction to researchers new to this area on how to conceptualize and navigate the field of D&I science, with the ultimate goal of increasing the reach and impact of evidence-based interventions.

Decision-making under clinical uncertainty: An in-depth examination of provider perspectives on adjuvant chemotherapy for stage II colon cancer.

OBJECTIVE: Decision-making about adjuvant chemotherapy (ACT) for stage II colon cancer is complex, particularly in light of clinical uncertainty regarding treatment benefits. Little is known about provider communication and factors influencing decision-making and recommendations in this setting. METHODS: We recruited providers from six US cancer centers and hospitals who care for stage II colon cancer patients. Providers participated in a 30-45 minute interview. Transcripts of interviews were coded for qualitative analysis. RESULTS: We interviewed 42 providers (Oncologists: 52%; surgeons: 24%; nurses: 14%). Though most providers were aware of stage II colon cancer treatment guidelines, their use and communication of recommended guidelines was limited. Most reported tailoring delivery and content of their communication, often based on perceived patient education level, but patient involvement in decision-making varied. Findings highlight the complexity of, ACT decision-making, including the central role of providers and family members. CONCLUSIONS: Providers are not consistently following recommended guidelines for communicating about ACT among stage II colon cancer patients or eliciting patient preferences for involvement in treatment decisions. PRACTICE IMPLICATIONS: Given clinical uncertainty surrounding use of ACT for stage II colon cancer, efforts are needed to enhance guideline implementation, provider education, and communication to facilitate decision-making.

Use of social network analysis in the development, dissemination, implementation, and sustainability of health behavior interventions for adults: A systematic review.

Interest in conceptualizing, measuring, and applying social network analysis (SNA) in public health has grown tremendously in recent years. While these studies have broadened our understanding of the role that social networks play in health, there has been less research that has investigated the application of SNA to inform health-related interventions. This systematic review aimed to capture the current applied use of SNA in the development, dissemination, implementation, and sustainability of health behavior interventions for adults. We identified 52 articles published between 2004 and 2016. A wide variety of study settings were identified, most commonly in the US context and most often related to sexual health and HIV prevention. We found that 38% of articles explicitly applied SNA to inform some aspect of interventions. Use of SNA to inform intervention development (as opposed to dissemination, implementation, or sustainability) was most common. The majority of articles represented in this review (n = 39) were quantitative studies, and 13 articles included a qualitative component. Partial networks were most represented across articles, and over 100 different networks measures were assessed. The most commonly described measures were network density, size, and degree centrality. Finally, very few articles defined SNA and not all articles using SNA were theoretically-informed. Given the nascent and heterogeneous state of the literature in this area, this is an important time for the field to coalesce on terminology, measures, and theoretical frameworks. We highlight areas for researchers to advance work on the application of SNA in the design, dissemination, implementation and sustainability of behavioral interventions.