Wednesday, September 18, 2019

End of Life & Finding the Right Words to Stop Cancer Screening in Older Adults

Finding the Right Words to Stop Cancer Screening in Older Adults. Rebecca Voelker. JAMA, September 18, 2019. doi:10.1001/jama.2019.14732

During her geriatric medicine fellowship in 2012, Nancy Schoenborn, MD, took notice of the American Geriatrics Society’s new guideline on caring for older adults with multimorbidity. Its advice for clinicians to incorporate prognosis into their clinical decision-making “really made a lot of sense to me…and it was supported by evidence,” said Schoenborn, an associate professor in the Division of Geriatric Medicine and Gerontology at the Johns Hopkins School of Medicine.

But when she considered how physicians should implement that advice, she didn’t have the words for it. Literally. “[I]t wasn’t clear how we should talk about it,” she said. The issue was particularly salient in cancer screening guidelines, which often use life expectancy of less than 10 years as the time to stop screening. Especially in primary care settings, where most cancer screening takes place, Schoenborn struggled with how physicians should tell healthy older patients they no longer need a mammogram, prostate-specific antigen test, or other routine cancer screening.

“If they pointed to the [guideline] and said, ‘Look, it says don’t screen if you have less than 10 years to live,’…that’s not going to go over very well,” she said. So Schoenborn went straight to the front lines. She and her colleagues interviewed older adults and primary care clinicians about how to discuss life expectancy in clinical decision-making and stopping cancer screening. In their most recent study, the investigators compared perspectives from both sides.

The study’s “good news is that there are several common themes that both the physicians and the patients agreed upon,” said Alexia Torke, MD, associate professor of medicine at the Indiana University School of Medicine, who has published research on cancer screening cessation. “That provides a good, brief framework for starting off this conversation,” added Torke, who wasn’t involved in the study.

Benefits vs Harms

Clinicians and older adults agree that talks about stopping cancer screening should include a discussion of the benefits and harms. “Every screening test has risks,” noted Elizabeth Eckstrom, MD, MPH, chief of geriatrics at the Oregon Health & Science University. “Mammography is a perfect example because there are so many false-positives. [W]ith colonoscopy…you could perforate the colon at a time when the person should never have had the procedure in the first place.”

When they’re armed with information about the pros and cons of screening, older adults in the study said the decision on whether to have the test should be their own. Clinicians agreed. Said one clinician who was interviewed: “I tell them that we are a team, so I explain the information and…then I leave it up to them.” But if older patients forgo screening, they also don’t want to feel that they’re receiving less care. “I would not want to just [stop screening] and then just not do anything else,” an older adult in the study said.

Perhaps the chief worry among clinicians was that by suggesting it’s time to stop cancer screenings, patients could become angry and feel their physician was giving up on them. “That was really a major concern and barrier” for clinicians, Schoenborn said. Added Eckstrom: “It’s a big deal emotionally for a lot of doctors.”

But older patients said they wouldn’t think badly of their physician for suggesting it’s time to stop screening. “They were actually not as reluctant as the doctors thought,” Schoenborn noted. “Many of them were willing, some had already stopped, and if they trusted their doctor it was not necessarily perceived as a negative thing.” In fact, patients in the study hoped clinicians would find that perception reassuring, she added.

Between a Rock and the Guidelines

The hurdle is talking about life expectancy with older adults. “When people go in for a routine checkup and you’re going to talk about whether they should get a mammogram or a colonoscopy, they’re not expecting a decision about how long they’re going to live,” Torke said. “That’s something we need to consider if we’re even going to bring up that topic.”

In her study, Schoenborn said discussing life expectancy “did not really resonate with them…nobody liked that.” But when the subject was raised a little differently during the study—talking about ending cancer screening in terms of age, health status, and functional abilities—adults in the study were far more receptive. “Everyone thought that was a great idea,” she noted.

“So there was a disconnect in their perception between the inputs that we use to calculate life expectancy and the idea in the words of life expectancy itself,” Schoenborn said. “They didn’t really think about life expectancy as this conglomerate measure of their age, health, and function.”

That puts clinicians in a tough spot, she added. “They’re giving these guidances on what the ‘right thing to do’ is, but it’s in a language that they can’t just directly tell the patients very easily.”

Rather than use the guidelines’ blunt phrasing about life expectancy, clinicians can frame the message for older patients whose other health issues are of greater concern than cancer screening. For example, Eckstrom noted, explaining to an older woman that finding ways to help prevent her frequent falls is a priority over mammography.

Focusing on other health priorities “hopefully would give [clinicians] some place to start to have that conversation,” Schoenborn said. Eckstrom also has another strategy. “Sometimes I say, ‘You get to graduate from cancer screening; it’s a good thing. You don’t need this anymore,’” she explained. Some of her patients are relieved to learn they no longer need cancer screening tests. “Who wants another colonoscopy in their 80s?” she said.

But even if clinicians find the right words, institutional barriers can get in their way. Some insurance companies offer incentives for physicians to screen patients, but “they’re not putting upper age limits on it,” Eckstrom said. So instead of being made to feel their performance is subpar, physicians order the tests.

Automated computer systems in clinics and hospitals where physicians “have to click through a lot of things not to do something” also pose obstacles, Schoenborn said. And then there are radiology departments that send routine reminders about mammograms, she added. So some patients who had decided to stop screening for breast cancer go in for a mammogram because a reminder told them they’re due.

The Flip Side of Success

Decades of public health messages have emphasized the importance of cancer screening. “We have these very clear, consistent messages that sit on the side of a [mailbox] or on a billboard: get your colonoscopy,” Torke said.

Clinicians and patients get into the routine of regular screening, and advocacy groups sport pink ribbons to encourage mammograms. “There is a lot of emotional attachment to doing that,” Schoenborn said. “It’s part of being a good citizen.”

But the time may be ripe for a “more public health approach to raise awareness in the public that stopping screening can be the right thing,” she added. “Maybe a first step is just to raise awareness that it’s not something we all have to do until we die.”

The Lure of Counterfactual Curiosity: We are willing to seek information about how much they could have won, even at a cost, and even though it has a negative emotional impact (it leads to regret)

FitzGibbon, Lily, Asuka Komiya, and Kou Murayama. 2019. “The Lure of Counterfactual Curiosity: People Incur a Cost to Experience Regret.” OSF Preprints. September 18. doi:10.31219/

Abstract: After making a decision, it is sometimes possible to seek information about how things would be if one had acted otherwise. In the current study we investigated the seductive lure of this counterfactual information, namely counterfactual curiosity. We demonstrate in a set of five experiments using an adapted Balloon Analogue Risk Task with varying costs of information, that people are willing to seek information about how much they could have won, even at a cost, and even though it has a negative emotional impact (it leads to regret). We go on to show that despite its lack of utility, people increased their risk-taking after receiving information about large missed opportunities, leading to poorer future outcomes. This suggests that information about counterfactual alternatives has incentive salience properties – people simply cannot help seeking it.

Educational attainment and achievement: Heritability is generally higher at greater equality levels, suggesting that inequality stifles the expression of educationally relevant genetic propensities

Genes and Gini: What inequality means for heritability. Fatos Selita and Yulia Kovas. Journal of Biosocial Science, Volume 51, Issue 1, January 2019, pp. 18-47.

Summary: Research has established that genetic differences among people explain a greater or smaller proportion of the variation in life outcomes in different environmental conditions. This review evaluates the results of recent educationally relevant behavioural genetic studies and meta-analyses in the context of recent trends in income and wealth distribution. The pattern of results suggests that inequality and social policies can have profound effects on the heritability of educational attainment and achievement in a population (Gene–Gini interplay). For example, heritability is generally higher at greater equality levels, suggesting that inequality stifles the expression of educationally relevant genetic propensities. The review concludes with a discussion of the mechanisms of Gene–Gini interplay and what the findings mean for efforts to optimize education for all people.

Rolf Degen summarizing: The sensory brain responds at first more strongly to expected events, then to the unexpected

Press, Clare, Peter Kok, and Daniel Yon. 2019. “The Perceptual Prediction Paradox.” PsyArXiv. August 14. doi:10.31234/

Abstract: From the noisy information bombarding our senses our brains must construct percepts that are veridical – reflecting the true state of the world – and informative – conveying the most important information for adjusting our beliefs and behaviour. Influential theories in the cognitive sciences suggest that both of these challenges are met through mechanisms that use expectations about the likely state of the world to shape what we perceive. However, current models explaining how expectations render perception either veridical or informative are mutually incompatible. Given the multitude of domains applying these conflicting models, it is essential that we consider whether and how this paradox can be resolved. We contend that ideas from the research on learning and inference may offer a resolution.

Tribalism and tribe survival: Governments and other entities sponsoring mass weddings

Here Comes the Bride. And the Bride. And the Bride. Mass Weddings Boom in Lebanon. Ben Hubbard. The New York Times, Sept. 15, 2019.

BKERKE, Lebanon — Classical music swelled as the bride stepped from a white sedan onto a red carpet, took the arm of her tuxedoed groom and walked down the aisle, both grinning as their relatives cheered nearby.

The next bride did the same. And the next. And the next. And the next.

Once the couples — 34 that day — reached their seats, the patriarch of the Maronite Church, dressed in crimson robes and gripping a scepter topped with a golden cross, led Mass and declared the whole lot husbands and wives.

It was Lebanon’s fourth mass wedding in three weeks, representing a social phenomenon that has been growing here and across the Middle East.

In a region where marriage remains highly valued but economic pressures and costly celebrations have priced many couples out, powerful benefactors have stepped in, sponsoring large-scale ceremonies to make sure that young people get hitched.

[Image Nineteen couples gathered at a resort in Jiyeh, Lebanon, last month for a mass wedding organized by Oasis of Hope, a group linked to a Shiite political party.CreditDalia Khamissy for The New York Times]

Politics, faith and Lebanon’s complicated demographics play a role too, in this country with 18 officially recognized sects.

Political parties sponsor weddings for young members to reinforce their loyalty, and gratitude. Religious and ethnic minorities — which means everyone in splintered Lebanon — consider marriage and procreation essential to their long-term survival. And armed groups encourage their fighters to marry so that their children can become the fighters of the future.

A few weeks before the Maronite nuptials, Hezbollah, the Shiite militant group and political party, oversaw a similar enormous wedding for 31 couples. That was tiny compared with a mass wedding in Lebanon earlier this year that brought together 196 couples and was sponsored by the Palestinian Authority president, Mahmoud Abbas.

But the nearby Gaza Strip — where an Egyptian-Israeli blockade keeps people poor and locked in — beats them all, often because of competition between foreign sponsors eager to win friends by expediting marriages.

In 2015, the United Arab Emirates sponsored a mass wedding there for 200 couples. Two months later, Turkey seriously upped the ante, bankrolling a ceremony for 2,000 couples that was attended by officials from Hamas, the militant group that rules the territory.

[Image Part of the Maronite ceremony in Bkerke. Most couples join mass weddings for financial reasons, because they cannot afford their own celebrations.CreditDalia Khamissy for The New York Times]

Mass weddings hold a lot of appeal for couples who cannot afford their own celebrations, or want to spend their money on other things, like building homes or starting businesses.

“They take care of everything, God bless them,” said Roni Abu Zeid, 35, who got married in the Maronite mass wedding, which was held in Bkerke, a town near the Mediterranean coast, north of Beirut. It is the headquarters of the Maronite Church.

Mr. Zeid is a soldier, and with his salary it was difficult to save the $20,000 he needed to outfit a home and host his own wedding party. So he gladly joined the mass wedding.

“If we got married elsewhere, we would have suffered,” he said.

His wedding was sponsored by the Maronite League, a nonprofit group associated with the church. Maronites are the largest of the Christian groups that make up about 36 percent of Lebanon’s population.

Fadi Gerges, an official with the league, said it was natural for minorities to encourage their youths to procreate in a country where demographics affect power.

“When any ethnic group feels they are in danger, they pull together,” he said. “When they see the numbers going up on the other side, they think maybe they can place a pebble to prevent a landslide.”

This year’s mass wedding was the group’s 10th in 11 years, bringing the number of couples it has married to 274. So far, those unions have resulted in only three divorces and more than 100 children.
After dinner in Jiyeh, the families took photos of a large, tiered cake.CreditDalia Khamissy for The New York Times

To be part of the league’s group ceremony, couples must apply. At least one of the couple must be a Maronite, and the groom must have a house and a job.

Accepted couples get a free suit for the groom, a dress for the bride, invitations, flowers, photos, $2,000 in cash and a blessing from the patriarch — a big bonus for the devout.

During the ceremony, the couples came forward one by one to say their “I dos” while their families clapped and ululated from the audience. A camera on a crane shot footage for a television broadcast while a drone zoomed about filming the proceedings.

The league once provided refreshments, but unfortunate jostling between families for drinks and snacks put an end to that, Mr. Gerges said.

[Image Oasis of Hope, a group that sponsored the wedding in Jiyeh, also helped the couples set up homes, giving them furniture and appliances.CreditDalia Khamissy for The New York Times]

The league gives couples marital support as needed while encouraging procreation. This year, it will outfit a nursery for the first 10 couples to give birth. Other religious and political groups provide different perks.

The same week as the wedding in Bkerke, 19 couples gathered at a resort in Jiyeh, a beachfront town south of Beirut, for another mass wedding organized by Oasis of Hope, a volunteer group linked to the Amal Movement, a Shiite political party.

Tables adorned with white cloths, candles and appetizers filled the lawn and surrounded the swimming pool, rare luxuries for the mostly poor families who came to see their young people wed.

Fatima Qabalan, an organizer, said the group had married about 300 couples in 12 mass weddings over the years. It not only provided them with a fancy celebration they could not otherwise afford, but helped them set up homes, giving them furniture and appliances.

[Image Ghassan Mohsen taking a photograph of his new wife, Huda Mallah, by the sea in Jiyeh.CreditDalia Khamissy for The New York Times]

The group gave precedence to the children of party members who had been wounded or killed in Lebanon’s wars, but also to the poor, to help their marriages get off the ground.

“If we didn’t help them start and set up their home, they would be going into debt and heading for failure,” Ms. Qabalan said.

While waiters in starched shirts distributed trays of grilled meat and piles of rice and fish, party officials gave speeches and a prominent journalist took to the microphone to remind the couples of the importance of childbearing to the “resistance,” or the struggle against Israel.

A dance troupe stormed in, banging drums, chanting and waving flaming batons and giant red hearts. Then the couples proceeded through the crowd, the grooms in black suits and ties, and the brides in white dresses with attached hair veils. Their relatives snapped photos as they passed.

Ali Ala’ideen, a groom whose hair was slicked back like Elvis’s, said that he and his new wife could not afford a honeymoon, but that he was grateful to be married.

“If it wasn’t a group wedding,” he said, “we wouldn’t have been able.”

After dinner, the families took photos of a large, tiered cake. Fireworks boomed over the Mediterranean, there was a bit of dancing, and the couples left to start their lives together.

One groom, Abdullah Dbouk, said his wife had caught his eye when he was hospitalized for appendicitis and saw her working as a nurse. Once he was out, he tracked down her family.

“As soon as I could walk, I went to see them,” he said.

The couple visited and chatted on Facebook for months before getting engaged, but lacked the money for a big wedding party. So they asked officials from the Amal Movement if they could join the mass wedding.

“It was fate,” said the bride, Nour Awarkeh, 20.

“Thank God for the appendicitis!” said the 26-year-old groom.

Follow Ben Hubbard on Twitter: @NYTBen

Hwaida Saad contributed reporting.

A version of this article appears in print on Sept. 15, 2019, Section A, Page 8 of the New York edition with the headline: Here Come the Brides. (This Time, 34 of Them.).

Diners paying with cash received either $1 or $6 of change over the correct amount; in 128 out of 192 tables, the diners did not return the excessive change; women returned the extra change much more often than men

The cost of being honest: Excessive change at the restaurant. Chp 4.2 in Dishonesty in Behavioral Economics - Perspectives in Behavioral Economics and the Economics of Behavior, 2019, Pages 267-288. Ofer H. Azar, Shira Yosef, Michael Bar-Eli.

Abstract: In a field experiment conducted in an Israeli restaurant, diners paying with cash received either 10 or 40 Shekels (about €2 or €8) of change over the correct amount. In 128 out of 192 tables, the diners did not return the excessive change. Women returned the extra change much more often than men, especially among repeated customers. Interestingly, a table with a woman and a man resembles a male table and not a female table. Repeated customers returned the excessive change much more often than one-time customers. Tables with two diners were not significantly more likely to return the excessive change than tables with one diner. We hypothesized that customers will return more often 10 extra Shekels than 40, but found a strong pattern in the opposite direction. This implies that in some situations the psychological cost of dishonest behavior increases more rapidly than the amounts involved.

People dislike telling lies; Business and Economics (B&E) students are significantly less lie averse than others; female B&E students tell the truth least often, whereas female students from other majors do so most often

Do economists lie more? Chp 3.1 in Perspectives in Behavioral Economics and the Economics of Behavior, 2019, Pages 143-162. Raúl López-Pérez, Eli Spiegelman.

Abstract: Experimental evidence suggests that some people dislike telling lies, and tell the truth even at a cost. We also use experiments, to study the sociodemographic covariates of such lie aversion. We find political ideology and religiosity to be without predictive value; however, subjects’ major is predictive: Business and Economics (B&E) subjects are significantly less lie averse than other majors. This is true even after controlling for subjects’ beliefs about the overall rate of deception, which predict behavior very well. Although B&E subjects expect most others to lie in our decision problem, the effect of the field of study remains. Regarding gender, females and males are equally likely to be lie-averse. In a more disaggregated analysis, however, we also observe that female B&E students tell the truth least often, whereas female students from other majors do so most often. These differences between female students, not observed for the males, seem in fact to drive the larger part of the differences between B&E and the other students.

Reward, pleasure, threat, fear, and disgust are emotional labels that we often use with confidence, as if we knew the identity of their corresponding psychological processes

A Liking Versus Wanting Perspective on Emotion and the Brain. Kent C Berridge. Chp 12 of The Oxford Handbook of Positive Emotion and Psychopathology, June Gruber (Ed.). 2019

Abstract: Reward, pleasure, threat, fear, and disgust are emotional labels that we often use with confidence, as if we knew the identity of their corresponding psychological processes. Those psychological processes of emotion are quite real and deeply grounded in brain systems shared by humans with many animals. But, the identity of fundamental psychological components within emotion are sometimes mistaken because only the final products are experienced, losing the identity of important psychological components that arise en route. Some of those components can have counterintuitive psychological features. For example, the experience of pleasant rewards actually contains distinct psychological processes of “liking” (hedonic impact) and “wanting” (incentive salience). Experience of fear-evoking threats hides distinct psychological components of passive reaction and an actively coping form of fearful salience. Perhaps most counterintuitively, the component of “fear” salience in threat shares a hidden psychological and neural relationship to that of “wanting” for rewards. These psychological components have implications both for ordinary emotions and for pathological disorders ranging from addiction to paranoia. Affective neuroscience studies in this way can produce surprises and insights into the psychological structure of emotions.

Keywords: emotion, affect, brain studies, wanting, liking, subjective feelings, emotional reactions