Cancer Screening in Elderly Patients

Abstract

Considerable uncertainty exists about the use of cancer screening tests in older people, as illustrated by the different age cutoffs recommended by various guideline panels. We suggest that a framework to guide individualized cancer screening decisions in older patients may be more useful to the practicing clinician than age guidelines. Like many medical decisions, cancer screening decisions require weighing quantitative information, such as risk of cancer death and likelihood of beneficial and adverse screening outcomes, as well as qualitative factors, such as individual patients' values and preferences. Our framework first anchors decisions through quantitative estimates of life expectancy, risk of cancer death, and screening outcomes based on published data. Potential benefits of screening are presented as the number needed to screen to prevent 1 cancer-specific death, based on the estimated life expectancy during which a patient will be screened. Estimates reveal substantial variability in the likelihood of benefit for patients of similar ages with varying life expectancies. In fact, patients with life expectancies of less than 5 years are unlikely to derive any survival benefit from cancer screening. We also consider the likelihood of potential harm from screening according to patient factors and test characteristics. Some of the greatest harms of screening occur by detecting cancers that would never have become clinically significant. This becomes more likely as life expectancy decreases. Finally, since many cancer screening decisions in older adults cannot be answered solely by quantitative estimates of benefits and harms, considering the estimated outcomes according to the patient's own values and preferences is the final step for making informed screening decisions.

Self-Reported Health Status Predicts Other-Cause Mortality in Men with Localized Prostate Cancer: Results from the Prostate Cancer Outcomes Study

“…11 The American Urological Association (AUA) treatment guideline suggests using life-table analyses to inform treatment decisions, 2 but these population-based estimates exclude health status and may not be readily applicable to predicting the life expectancy of an individual patient. 12 Indeed, life tables have been shown to have limited predictive value for men undergoing radiation therapy 13 or radical prostatectomy. 6 While some multivariate predictive models, particularly those incorporating comorbidity, appear to accurately estimate life expectancy, [14][15][16][17][18] their performance for men with prostate cancer is variable or unknown.…”

An Individualized Approach to Cancer Screening Decisions in Older Adults: A Multilevel Framework

“…46 Using the IDS framework, however, healthcare organizations could provide clinicians with individualized rates of screening by patient health category (using the Charlson Comorbidity Index). 1,3,4 Ideally, clinicians would see high screening rates among those in good health and low screening rates among those in poor health. Healthcare claims datasets linked to individualized decisions between clinicians and patients, together with organizational quality surveys of patient well-being, could provide a feedback loop among distal outcome measures, patients, clinicians and organizations.…”

“…43 Furthermore, evidence suggests that even among patients who prefer a passive role in medical decisions, 41,[49][50][51] many still want to be informed and have their values considered. 4,51 At the healthcare organization level, the individualized decision-making process necessitates close collaboration between clinicians and healthcare organizations to ensure timely and appropriate follow-up care. 29,52 In some instances, this requires the interdisciplinary collaboration of primary care clinicians, radiologists, surgeons, or pathologists to ensure necessary diagnostic work-up, intervention, or follow-up care.…”

“…2,3 Recent guidelines encourage an individualized decisionmaking approach among older adults, where the risks and benefits of screening tests are weighed and the quantity and quality of life are considered. 1,3,4 These considerations are foundational to informing patient screening choices. 5,6 In clinical practice, implementation of preference-sensitive cancer screening depends on factors at the patient, clinician, and healthcare organization levels.…”

Life expectancy estimation in prostate cancer patients

“…For example, 70-year-old men could have up to 11.3 years of LE disparity based solely on their comorbidities. 6 Currently, apart from empiric LE predictions based on life experience and personal belief, various tools can assist physicians in the process of LE estimation in prostate cancer patients. These consist of life tables from Statistics Canada, comorbidity indices (i.e., Charlson Comorbidity Index) and multivariate prognostic models (i.e., nomograms).…”