Age-based cancer screening guidelines not sophisticated enough for most elderly, SFVAMC paper argues

By Kevin Boyd

Cancer screening guidelines that recommend a test based on age are too
simplistic, argues a new study from the San Francisco Veterans Affairs Medical
Center.  The authors recommend a more individualized approach based on a
patient’s preferences, as well as life expectancy and other characteristics.

According to the study, published in the latest issue of the Journal of the
American Medical Association, a framework that helps doctors to make
individualized cancer screening decisions should be more useful than age

Unfortunately, many health care agencies or insurers rely on age-based
guidelines for assessing quality or reimbursing for care, Walter said.

Because health status among the elderly varies much more from person to person,
screening decisions require a more rational approach in this population, said
lead author Louise Walter, MD, a geriatrics fellow at SFVAMC and the University
of California, San Francisco. 

“For almost any test, if the burdens outweigh the benefits the doctor
recommends against it, but with screening there seems to be more of a knee-jerk
approach, to screen patients up to a certain age and then stop,” she said.

In their new paper, Walter and her co-author lay out a series of steps for
doctors to follow, to help them decide rationally whether or not to screen an
elderly patient.

Doctors need more information about how to approach cancer screening in older
patients, Walter said. “We hope this paper will give doctors more confidence
in making rational decisions about whether or not to recommend screening, by
helping them consider a whole range of patient characteristics, and not just
age,” she said.

Walter’s co-author on the study was Kenneth Covinsky, MD, MPH, UCSF assistant
professor of medicine and SFVAMC staff physician.

One of the most important factors to consider, Walter said, is the patient’s
life expectancy.  “If a patient has other illnesses and only has a five-year
life expectancy, then it doesn’t make sense to screen them for breast cancer or
another cancer, when we know from research that patients do not benefit from
screening for at least five years,” she said.

For example, Walter said, a very healthy 80-year-old who might be expected to
live at least 13 years longer, is much more likely to be helped by cancer
screening than a 70-year-old with severe congestive heart failure and other
major health problems who is unlikely to live to age 75. 

The study includes charts that doctors can use to estimate life expectancy, and
the likelihood that a patient will benefit from screening for colorectal
cancer, breast cancer, or cervical cancer. 

In addition to possible benefits, doctors should consider the risks and burdens
inherent in every cancer screening test, Walter said.  Screening tests can be
inaccurate.  A test result that suggests the presence of cancer will cause the
patient anxiety and result in biopsies and other, often invasive follow-up
testing procedures.  Also, patients with limited life expectancies can suffer
unnecessary harm from finding an early cancer and having surgery or other
invasive treatments, because many cancers found by screening would not have
progressed quickly enough to affect them during their limited lifetime.

“For some elderly patients, especially for those with dementia, a screening
test and subsequent work-up can be a very traumatic, and even scary experience
that significantly reduces their quality of life,” Walter said.

But perhaps the most important consideration of all, the researchers said, is
the patient’s own preferences. “It is very important to talk to older patients
about their preferences, because frequently a simple comparison of benefits and
harms doesn’t yield a clear recommendation.  Some patients feel they will get
much relief and piece of mind from having a screening test, and in other cases
people really don’t want to have a test if they can avoid it,” Walter said. 

“Hopefully, our screening framework will help stimulate discussions about
cancer screening and promote informed decisions,” she said