Unlikely to Benefit, Older Adults Still Get Cancer Screening

Roxanne Nelson

August 18, 2014

A substantial proportion of older people in the United States continue to undergo cancer screening, even though they are unlikely to benefit from it.

A large population-based study that used data from the National Health Interview Survey (NHIS) found that more than half of all people 65 years and older who had a life expectancy of less than 9 years had received prostate, breast, cervical, or colorectal cancer screening.

The study results are published online August 18 in JAMA Internal Medicine.

The researchers, led by Trevor J. Royce, MD, MS, from the University of North Carolina at Chapel Hill, analyzed 2000 to 2010 NHIS data on cancer screening for 27,404 people 65 years and older.

Participants were grouped by mortality risk. A 25% risk for death within 9 years was considered low, a 25% to 49% risk was considered intermediate, a 50% to 74% risk was considered high, and a risk of 75% or more was considered very high.

Table. Screening Rates

Cancer Screening Overall, % Low-Risk Group, % Very-High-Risk Group, %
Prostate 64 70 55
Breast 63 74 38
Cervical 57 70 31
Colorectal 47 51 41


In the very-high-risk group, rates ranged from 55% for prostate cancer screening to 31% for cervical cancer screening. For women who had undergone a hysterectomy for a benign condition, 34% to 56% had undergone Pap testing in the previous 3 years.

In multivariate models, an increased risk for mortality was associated with a decreased odds of cancer screening for all cancers except colorectal. Older age was also independently associated with less screening for all cancers. In addition, rates of screening for prostate and cervical cancers were lower at the end of the study period than at the beginning.

People 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 healthcare expenditure but can lead to patient net harm," the researchers write.

Because questions are being raised about the benefit of some methods of cancer screening, it is particularly important to question the use of these strategies in older people, Cary P. Gross, MD, from the Yale University School of Medicine in New Haven, Connecticut, writes in an accompanying commentary.

People with a shorter life expectancy have less time to develop clinically significant cancers after screening tests and are more likely to die from other causes, he explains. In addition, the patterns of care found by Dr. Royce and colleagues are in conflict with several guidelines that "advise against screening patients with a short life expectancy."

Three Steps to Improvement

When there is uncertainty about the risk/benefit ratio, "we need to bolster our efforts to generate evidence that can inform cancer screening decisions," Dr. Gross says, and he suggests a 3-step approach.

First, physicians need to alter their approach when discussing screening. "Because of the substantial heterogeneity in life expectancy and comorbidity burden, assessment of life expectancy should inform individual decision making," he notes.

Second, Medicare reimbursement policies for services that are "reasonable and necessary" warrant scrutiny. "When is it 'reasonable' or 'necessary' to perform a procedure on an asymptomatic older person if risks are likely to outweigh the benefits?" Dr. Gross asks.

Finally, quality measures are needed to address overscreening, including that for cancer care. "For years, receipt of cancer screening has been a core element used to assess quality of care, to address the concern of underscreening," he points out. But, in a "marked departure from this focus on increasing screening use, the National Committee for Quality Assurance has recently released proposed overuse measures for inclusion in their HEDIS 2015 measurement set."

More Risk Than Benefit?

Other studies are beginning to examine the risk and benefit of cancer screening in older people with a limited lifespan. In a study published in the same issue of JAMA Internal Medicine, researchers examined whether more intensive colorectal cancer screening with colonoscopy is beneficial to Medicare recipients. All guidelines recommend a screening interval of 10 years for colonoscopy in average-risk patients, but recent studies indicate that many Medicare beneficiaries are being screened more frequently, note Frank van Hees, MSc, from the Department of Public Health at Erasmus University Medical Center in the Netherlands, and colleagues. One in 5 individuals with a negative test are having a repeat colonoscopy within 5 years instead of after 10 years, and 1 in 4 who have a negative test at 75 years or older receive "yet another screening colonoscopy at an even more advanced age," they report.

Dr. van Hees's team used a microsimulation model to determine whether screening more often than recommended is beneficial, and whether any benefit justifies the additional resources required. They found that screening older people more often than recommended is not only "inefficient from a societal perspective, often it is also unfavorable for those being screened."

A study published last year found that screening for breast and colorectal cancer should be targeted at people who have a life expectancy of more than 10 years (BMJ. 2013;345:e8441). In that study, the researchers found that the harms of screening outweigh the benefits for most people with a life expectancy of less than 5 years, although they caution that these results should not be used to deny screening to people with a limited life expectancy. Instead, the study results should be used to "inform individualized decision making, which aims to account for patient preferences and values while maximizing benefits and minimizing risks," the researchers explain.

The study was funded in part by a grant from the Doris Duke Charitable Foundation to the University of North Carolina at Chapel Hill. The authors have disclosed no relevant financial relationships. Dr. Gross reports financial relationships with FAIR Health, Medtronic, Johnson & Johnson, and 21st Century Oncology.

JAMA Intern Med. published online August 18, 2014. Abstract, Commentary


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