Older Patients With Limited Life Expectancy Still Receiving Cancer Screenings

The routine screening procedures are unlikely to benefit them

A substantial number of older patients with limited life expectancy continue to receive routine screenings for prostate, breast, cervical and colorectal cancer although the procedures are unlikely to benefit them. The paper authored by Dr Trevor Royce of the University of North Carolina at Chapel Hill and colleagues is published online first on 18 August 2014 in the journal JAMA Internal Medicine.

An aim of Healthy People 2020 is to increase the proportion of individuals who receive cancer screening consistent with the USA Preventive Services Task Force's (USPSTF) evidence-based guidelines. And there is general agreement that routine cancer screening is unlikely to benefit patients with limited life expectancy.

The authors examined rates of prostate, breast, cervical and colorectal cancer screening in patients 65 or older using data from the USA National Health Interview Survey from 2000 through 2010. The study included 27,404 participants who were grouped by risk (low to very high) of nine-year mortality.

Low mortality risk was defined as less than 25% and very high mortality risk was 75% or more.

Results

In patients with very high mortality risk, 31% to 55% received recent cancer screening, with prostate cancer screening being the most common (55%). For women who had a hysterectomy for benign reasons, 34% to 56% had a Papanicolaou test within the past three years.

The overall screening rates for the study group were prostate cancer, 64% (ranging from 70% in individuals with low mortality risk to 55% in those with very high mortality risk); breast cancer, 63% (ranging from 74% among people with low mortality risk to 38% in patients with very high mortality risk); cervical cancer, 57% (ranging from 70% among low mortality risk patients to 31% in patients with very high mortality risk); and colorectal cancer, 47% (ranging from 51% for low-mortality risk patients to 41% for patient with very high mortality risk).

There was less screening for prostate and cervical cancers in more recent years compared with 2000. Older age was associated with less screening for all cancers. Patients who were married, had more education, had insurance, or had a usual place for care were more likely to be screened.

"These results raise concerns about overscreening in these individuals, which not only increases health care expenditure but can lead to patient net harm. Creating simple and reliable ways to assess life expectancy in the clinic may allow reduction of unnecessary cancer screening, which can benefit the patient and substantially reduce health care costs. There is considerable need for further dissemination efforts to educate physicians and patients regarding the existing screening guidelines and potential net harm from screening in individuals with limited life expectancy."

Simulated modeling study

In 'Modeling Study Analyzes Colonoscopy Screening of Medicare Patients,' author Frank van Hees, MSc, of Erasmus University Medical Center, the Netherlands, and colleagues concluded in a simulated modeling study that screening Medicare beneficiaries with colonoscopies more regularly than recommended resulted in only small increases in prevented colorectal cancer deaths and life-years gained but large increases in colonoscopies performed and colonoscopy-related complications.

All guidelines for colorectal cancer screening recommend a screening interval of 10 years for colonoscopy screening in average-risk patients. The USPSTF and the American College of Physicians recommend against routine screening in adults older than 75 years with an adequate screening history.

The authors used a microsimulation model to estimate whether more intensive screening than recommended was beneficial to Medicare beneficiaries, as well as whether any benefit justified the additional resources required.

Screening Medicare beneficiaries with a negative screening colonoscopy result at 55 years according to current guidelines (e.g. screening again at 65 and 75) resulted in 14.1 colorectal cancer cases prevented, 7.7 colorectal cancer deaths prevented and 63.1 life-years (LYs) gained per 1,000 beneficiaries compared with no screening.

Compared with screening every 10 years, screening every 5 years resulted in 1.7 additional colorectal cancer cases prevented, 0.6 additional colorectal cancer deaths prevented, 5.8 additional LYs gained and prevented 10.9 additional LYs with colorectal cancer care per 1,000 beneficiaries. To achieve this small benefit, 783 more colonoscopies had to be performed.

"Screening Medicare beneficiaries more intensively than recommended is not only inefficient from a societal perspective; often it is also unfavorable for those being screened. This study provides strong evidence and a clear rationale for clinicians and policy makers to actively discourage this practice."

Expert commentary

In a related commentary, Dr Cary Gross of the Yale University School of Medicine, writes: "Cancer screening in the 21st century, however, is losing its luster. Increasing evidence suggests that many modalities of cancer screening may be far less beneficial than first thought."

"It is particularly important to question screening strategies for older persons. Patients with a shorter life expectancy have less time to develop clinically significant cancers after a screening test and are more likely to die from noncancer health problems after a cancer diagnosis. In addition, older persons face a higher risk of complications from procedures such as screening colonoscopy. In this context, two articles in this issue of JAMA Internal Medicineare informative," Gross continues.

"It truly will be a new era when providers will be evaluated, in part, by their ability to refrain from ordering cancer screening tests for some of their patients. We are moving toward a time when prevention efforts will be more evidence based, more effective and patient centered. What could be more wonderful than that?" Gross concludes.

References

Royce TJ, Hendrix LH, Stokes WA, et al.Cancer Screening Rates in Individuals With Different Life Expectancies. JAMA Intern Med 2014; Published online August 18. doi:10.1001/jamainternmed.2014.3895

van Hees F, Zauber AG, Klabunde CN, et al.The Appropriateness of More Intensive Colonoscopy Screening Than Recommended in Medicare Beneficiaries: A Modeling Study. JAMA Intern Med 2014; Published online August 18. doi:10.1001/jamainternmed.2014.3889

Gross CP. Cancer Screening in Older Persons:  A New Age of Wonder. JAMA Intern Med 2014; Published online August 18. doi:10.1001/jamainternmed.2014.3901