Cancer : screening prescriptions decline later in day

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Cancer has a major impact on society in the United States and across the world. Cancer statistics describe what happens in large groups of people and provide a picture in time of the burden of cancer on society.

Statistics tell us things such as how many people are diagnosed with and die from cancer each year, the number of people who are currently living after a cancer diagnosis, the average age at diagnosis, and the numbers of people who are still alive at a given time after diagnosis.

They also tell us about differences among groups defined by age, sex, racial/ethnic group, geographic location, and other categories.

Although statistical trends are usually not directly applicable to individual patients, they are essential for governments, policy makers, health professionals, and researchers to understand the impact of cancer on the population and to develop strategies to address the challenges that cancer poses to the society at large.

Statistical trends are also important for measuring the success of efforts to control and manage cancer.

Statistics at a Glance: The Burden of Cancer in the United States

  • In 2018, an estimated 1,735,350 new cases of cancer will be diagnosed in the United States and 609,640 people will die from the disease.
  • The most common cancers (listed in descending order according to estimated new cases in 2018) are breast cancer, lung and bronchus cancer, prostate cancer, colon and rectum cancer, melanoma of the skin, bladder cancer, non-Hodgkin lymphoma, kidney and renal pelvis cancer, endometrial cancer, leukemia, pancreatic cancer, thyroid cancer, and liver cancer.
  • The number of new cases of cancer (cancer incidence) is 439.2 per 100,000 men and women per year (based on 2011–2015 cases).
  • The number of cancer deaths (cancer mortality) is 163.5 per 100,000 men and women per year (based on 2011–2015 deaths).
  • Cancer mortality is higher among men than women (196.8 per 100,000 men and 139.6 per 100,000 women). When comparing groups based on race/ethnicity and sex, cancer mortality is highest in African American men (239.9 per 100,000) and lowest in Asian/Pacific Islander women (88.3 per 100,000).
  • In 2016, there were an estimated 15.5 million cancer survivors in the United States. The number of cancer survivors is expected to increase to 20.3 million by 2026.
  • Approximately 38.4% of men and women will be diagnosed with cancer at some point during their lifetimes (based on 2013–2015 data).
  • In 2017, an estimated 15,270 children and adolescents ages 0 to 19 were diagnosed with cancer and 1,790 died of the disease.
  • Estimated national expenditures for cancer care in the United States in 2017 were $147.3 billion. In future years, costs are likely to increase as the population ages and cancer prevalence increases. Costs are also likely to increase as new, and often more expensive, treatments are adopted as standards of care.

U.S. Cancer Mortality Trends

The best indicator of progress against cancer is a change in age-adjusted mortality (death) rates, although other measures, such as quality of life, are also important. Incidence is also important, but it is not always straightforward to interpret changes in incidence.

For example, if a new screening test detects many cancer cases that would never have caused a problem during someone’s life (called overdiagnosis), the incidence of that cancer would appear to increase even though the death rates do not change.

But a rise in incidence can also reflect a real increase in disease, as is the case when an increase in exposure to a risk factor causes more cases of cancer.

In this scenario the increased incidence would likely lead to a rise in mortality from the cancer.

Compared to patients who see their primary care doctor earlier in the day, cancer screening rates decline significantly as the day goes on, according to a new study from researchers in the Perelman School of Medicine and the Wharton School both of the University of Pennsylvania.

The researchers, whose findings were published today in JAMA Network Open, believe these rates of decline may be in part due to “decision fatigue”- which results from the cumulative burden of screening discussions earlier in the day – and doctors falling behind in their busy schedules.

“Our findings suggest that future interventions targeting improvements in cancer screening might focus on time of day as an important factor in influencing behaviors,” said the study’s lead author, Esther Hsiang, a Wharton Business School student and researcher with the Penn Medicine Nudge Unit.

“We believe that the downward trend of ordering may be the result of ‘decision fatigue,’ where people may be less inclined to consider a new decision after they’ve been making them all day.

It may also stem from overloaded clinicians getting behind as the day progresses.”

The researchers found that, among eligible patients, primary care doctors ordered breast cancer screening more often for patients seen in the 8 a.m. hour (64 percent) as compared to those with appointments at 5 p.m. (48 percent).

Similarly, for colon cancer screening, tests were also ordered more frequently for 8 a.m. patients (37 percent) compared to those coming in later in the day (23 percent).

Examining data from 2014 through 2016 across 33 Pennsylvania and New Jersey primary care practices, the researchers found that ordering rates had far-reaching effects.

When looking at the entire population eligible for screenings at these practices (roughly 19,000 for breast cancer and 33,000 for colorectal cancer), the researchers tracked whether the patients completed a screening within a year of their appointment.

The data showed that the downward trend associated with the timing of the appointments carried over.

Breast cancer screening – which included mammograms – stood at a 33 percent one-year completion rate for the entire eligible population who had their appointment in the 8 a.m. hour.

But for those who had clinic visits at 5 p.m. or later, just 18 percent completed screenings.

For colorectal cancer, screenings such as colonoscopies, sigmoidoscopies, and fecal occult blood tests were completed by 28 percent of the patients with appointments in the 8 a.m. hour.

That number dropped to 18 percent for patients who saw the doctor at 5 p.m. or later.

The one-year completion results cast long shadows.

While doctors may simply be deferring discussions about screening to future appointments, it assumes that the decision will be made the next time.

Additionally, these types of cancer screenings also require coordination with a different department and another visit on the part of the patient, which provide several opportunities for further lapses in screening.

Researchers also observed that although order rates fell as the day progressed, there was a brief spike in screening orders for breast and colon cancers when patients saw their clinician around noon.

For example, breast cancer screening orders dropped to 48.7 percent at 11 a.m. but increased to 56.2 percent around noon, before gradually falling off again.

This trend held true for one-year completion rates, as well.

The study team suggest that this may be due to lunch breaks that give clinicians and opportunity to catch up and start fresh.

A downward trend in outcomes by hour was noted in a study in 2018 examining the rates of flu vaccinations by the time of day when patients saw a clinician.

In that study, a “nudge” was built into the system that prompted doctors to accept or decline an influenza vaccine order, which helped spur an increase of vaccinations by nearly 20 percent, as compared to patients with doctors who weren’t nudged.

“Our new study adds to the growing evidence that time of day and decision fatigue impacts patient care,” said Mitesh Patel, MD, MBA, director of the Penn Medicine Nudge Unit and an assistant professor of Medicine.

“In past work, we’ve found that nudges in the electronic health record can be used to address these types of gaps in care, which we suspect will be the case here. Future research could evaluate how nudges may be implemented in order to improve cancer screening.”

More information:JAMA Network Open (2019). DOI: 10.1001/jamanetworkopen.2019.3403
Journal information: JAMA Network Open
Provided by Perelman School of Medicine at the University of Pennsylvania

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