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

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 guidelines.

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

The San Francisco Veterans Affairs Medical Center has been a primary affiliate of University of California, San Francisco since 1974. The UCSF School of Medicine and the SFVAMC collaborate to provide education and training programs for medical students and residents at SFVAMC. SFVAMC maintains full responsibility for patient care and facility management of the medical center. Physicians at SFVAMC are employed by the Department of Veterans Affairs and also hold UCSF faculty appointments.