Is Cancer Screening Justified in Patients With Reduced Life Expectancy?
There is very little published information on disease-specific cancer mortality rates in the transplant population; moreover, clinically important increases in mortality risk with immunosuppression have not been shown. This is important because transplant recipients have competing risks of death from cardiovascular disease (15 times more likely) and infection (3 times more likely) vs cancer. In addition, patients returning to dialysis after a failed transplant have even greater mortality than patients on the transplant waiting list.
A recent cost-effectiveness analysis demonstrated that the potential benefit of cancer screening in kidney transplant recipients was diminished largely due to the shortened life expectancy in this group. Diabetic recipients benefited the least because their life expectancies are projected to be the shortest. Intuitively, recipients with a failing allograft or severe comorbid disease are less likely to benefit from cancer screening. Evidence supporting routine screening for breast, colorectal, and prostate cancer in the general population cannot casually be generalized to the transplant population as malignancy rates much higher than are currently published will be required to demonstrate the benefit of this strategy. Instead, an individualized decision-making approach should be used.
Walter and Covinsky developed a framework for cancer screening in the elderly, and for the purposes of this discussion I am equating the elderly and kidney transplant recipients as similar with regard to reduced life expectancy, since uncertainty exists about the use of cancer screening tests in both groups. They recommend an individualized approach to cancer screening decisions as an alternative to age-specific guidelines. Their approach is based on 4 factors: risk of dying, benefits of screening, harm of screening, and assessment of values and preferences, specifically weighing the peace of mind that a patient might have from a negative test result against the potential harm of being frightened or agitated by the screening test. Although time consuming, this individualized approach is potentially valuable to patient, physician, and provider.
Using their framework, patients with a life expectancy of approximately 5-7 years would not be screened, since these patients are unlikely to derive any survival benefit from cancer screening. Included in this no-screen group would be those patients who are likely to lose their allograft within 5 years and who would not be candidates for retransplantation. In patients with more intermediate life expectancies (7-12 years), an informed discussion of potential benefit and harm and preferences is indicated.
Medscape Nephrology. 2005;2(2) © 2005 Medscape
Cite this: Screening and Early Detection: Cancer in the Kidney Transplant Recipient - Medscape - Dec 13, 2005.