During my training to become a primary care physician, the importance of preventive cancer screening was ingrained in me. The idea of catching cancer at an early stage so we can better treat it made intuitive sense. But as I’ve learned over the years, the simplicity of this concept can obscure its limitations and make it difficult to persuade older or sick individuals that screening can do them more harm than good.
Early in my career, I dutifully kept track of what cancer screening tests my patients needed and made sure to remind them about these tests. But after poring over the details of the evidence behind various screening tests, working with thousands of patients, and conducting formal interviews of patients and doctors about screening, I’ve developed a more nuanced approach.
The catch-cancer-early-save-a-life trope is a bit misleading: the benefit of some tests is smaller than I had initially thought. Say 1,000 women have biennial mammograms between the ages of 50 and 74. Those 12,000 mammograms would prevent seven deaths from breast cancer. Yearly PSA testing among 1,000 men between the ages of 55 and 69 would lead to one to two fewer deaths from prostate cancer.
Another often-overlooked aspect of screening is that the benefit isn’t immediate but lags by about 10 to 15 years for breast, colon, and prostate cancer. This means that if you look at one group of patients who got screened for these cancers and another group that did not, there would be no difference in deaths for 10 to 15 years.
If cancer screening had no side effects, then the small number of lives saved or the lag time wouldn’t matter. But there are downsides to cancer screening that can, at times, outweigh the small and delayed benefit.
The hazards of cancer screening became more relevant as I became a geriatrician and devoted myself to caring for older adults. Although some of my patients are still working full time or traveling the world in their 70s and 80s, I usually see patients who have accumulated a number of serious illnesses, need to take multiple medications, and can no longer manage their daily activities without help. These patients, whose life expectancies tend to be less than 10 years, are unlikely to reap a benefit from cancer screening and are at increased risk of experiencing short-term harms and burdens, including complications from screening and follow-up tests, over-diagnosis and over-treatment of clinically unimportant cancers, diverted attention from other health priorities, and psychological stress from false positive results.
Yet many of these patients are wary when I broach the idea of stopping screening.
To explore what older patients and their doctors think about stopping cancer screening, several colleagues and I interviewed 40 older adults and 28 primary care clinicians. As we wrote in the journal The Gerontologist, one theme that emerged among clinicians was that patients might interpret a recommendation to stop cancer screening as “giving up on them.” Patients, however, didn’t share that concern. As one older adult said, “I would think that [the clinician] would base saying something like that to me [on] facts that she studied.”
To counter any potential negative perceptions, both clinicians and patients suggested focusing on other health concerns. As one clinician said, “Let’s shift the focus to things that are more relevant right now.”
One area of difference between clinicians and patients is whether life expectancy should be part of the discussion about stopping cancer screening. Clinicians said they generally didn’t mention limited life expectancy as one of the reasons for stopping screening because they found it difficult to discuss the issue with patients, were concerned how they would react, and weren’t certain which patients would be open to having such a conversation.
Their concerns were somewhat justified. Although the older adults we interviewed thought that their clinicians should know what to say about life expectancy and how to say it, some wanted to hear about their life expectancies, some thought it was okay not discuss it, and others just didn’t want to hear about it.
There are several take-home messages from this work. One is that many older adults are willing to stop routine cancer screening when it makes sense to do so, especially when they trust their doctors. Another is that not all older adults may want to hear about life expectancy when thinking about cancer screening, and framing the decision as a shift in health priorities may be a better approach.
I still believe that cancer screening is a helpful intervention for many people — we just have to be better at recognizing when it stops being helpful.
Nancy L. Schoenborn, M.D., is a geriatrician and associate professor of medicine at Johns Hopkins University School of Medicine.
First of all, I wish we had more geriatricians. I mostly agree with you but I also think this needs to be very individualized. There is so much to consider and each case unique. Patient involvement is paramount. The actual age should not be a major consideration but overall health and patient expectations are so important. Example, my 83 year old father has extensive medical issues and advanced COPD, but his gastroenterologist still wanted him to schedule colon cancer screening. If the doctor had taken the time to explain the pros and cons and realistic progression of colon CA, he would have passed on the colonoscopy. He also wouldn’t want abdominal surgery with a partial colectomy or chemo if he did have colon CA. My mom is a super healthy 82-year-old and should absolutely have cancer screening if she wants it. I wouldn’t be surprised if she lives to be 100, but she should still have her options explained including pros and cons.
Great article. In my geriatric practice as a PA I would discuss end of life issues on the second visit. I hate being caught off guard if something bad happens to a patient. I did follow the routine screening recommendations. I also examined fully every patient and got a full history on them. Today my experience as a patent is no one exams you any more. Also routine blood work is not done unless there is a complaint. Therefore you can’t track
early trends. Bedside medicine has gone by the wayside!
You can thank the “standard of care” cookie cutter medicine for that. They have totally lost sight of the fact that medicine is an art as well as a science and NO two people react the EXACT same way to everything. Dilaudid wires me up like it was methamphetamine. Zofran makes me projectile vomit. This is the opposite reaction of both of these meds but I am unable to convince my doctors of this. It’s why I refused chemotherapy for my ovarian cancer and I am still alive nearly 4 years later and completely radiation and chemo naive.
This is nonsense. If I am in my eighties and have cancer, why should I pay someone through the nose to tell me what I already know? I will die no matter what cockamaimy treatment is thrust at me. I may diein pain, but I will not have given my estate to a bunch of medical trolls stuffing their pockets with my money.
This article is circular nonsense. A close friend of mine recently died of prostate/bone cancer ,after having his request for a prostate exam refused by his GP for 3 annual physicals in a row. Let PEOPLE control their own health and Doctors get off their high horses.
How old is old? My mother lived to be 97, which is 25 Years longer than I’ve lived at 72. My husband is 56 and I’ve been quite healthy all my life. Now only health issue is a bit of osteoarthritis in my hands just as my Mom had. We plan on traveling to Europe and Israel for the third time. People thought my mom looked in her 70s when she was 90. I feel my husbands age for the most part. What happened to 70 is the new 50 and all that?
I completed an NIH funded study to explore ways to improve cancer screening in primary care patients. Using a comprehensive approach, we increased cancer screening rates (colorectal cancer) from 12% to 68% among patients >49 years old. As a result of the study, I published a guide to cancer screening for family medicine residency programs designed to teach residents how to improve screening rates
I so agree with stopping screening.
My late mother became an invalid from a stroke in her early 80’s. She also had a heart attack and had a heart valve problem that could not be operated on due to her bad health. She also had terrible chronic pain from a shoulder problem, back issues, and more. And, she needed to wear a diaper.
Leaving her assisted living facility was an ordeal. My father, who is older than she was, had to deal with her wheelchair, and she often felt a lot of pain from getting in and out of the car. Even using the ALF’s van caused her pain.
When I heard that she had a mammogram, I was flabbergasted. What was the point? She certainly couldn’t have tolerated treatment for cancer, and, the mammogram must have been torture for her, along with getting to and from it. She couldn’t stand. My father had to help.
And what if she needed a biopsy? She couldn’t have tolerated that either. So, what was the point? I myself have had 2 biopsies due to lumps and mammograms; both negative thank goodness, but inconvenient and stressful, even though insurance paid.
When I told her that it made no sense to me given her age and condition, she told me it was the last one.
I didn’t know about it until after it was done. I wish I knew who knew and how the decision was made to go ahead with it. My father? My sisters? I would have tried to stop it.
don’t have a doctor and don’t want one but agree the fascination with screening for things leads to a lot of wasted resources.
great post http://www.statnews.com