I recognized a glitch in my electronic medical record’s decision support software when it prompted me to consider prostate and colorectal cancer screening in a 93-year-old man, who, though remarkably vigorous for his age, was unlikely to live for the additional 10 years needed to benefit from either test. Although deciding not to screen this patient was easy, determining when to stop cancer screening in older patients is often more challenging. In the American Family Physician, Drs. Brooke Salzman, Kathryn Beldowski, and Amanda de la Paz present a helpful framework for decision making in these clinical situations, where population-level guidance derived from studies of screening younger patients “generally do not address individual variations in life expectancy, comorbid conditions, functional status, or personal preference.”
The authors recommend that clinicians take into account not only average life expectancy at a given age, but also significant variations in life expectancy linked to functional impairment and comorbid conditions, using one or more validated prognostic tools. Although the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence about screening mammography in women 75 years or older, modeling studies suggest that women with projected life expectancies of greater than 10 years may still benefit from this test, with these important caveats:
Although the sensitivity and specificity of mammography increase with age, overdiagnosis also increases because of reduced life expectancy and an increased proportion of slower-growing cancers. In other words, women with breast cancer diagnosed at an older age are more likely to die of something else, compared with younger women. In addition, treatment of breast cancer in advanced age is associated with greater morbidity, including an increased risk of postoperative complications and toxicity from chemotherapy.
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