Too Many Cancer Screenings Wasted on Those Facing Death
Older patients who aren’t expected to live more than another decade are still being screened too often for cancers, causing more harm than good, a study found.
More than half of men 65 and older who had a very high risk of dying in nine years were screened for prostate cancer, a slow-moving disease, according to research today in JAMA Internal Medicine. Almost 38 percent of older women with a similar life expectancy were screened for breast cancer and 31 percent were screened for cervical cancer despite some having undergone a hysterectomy, which means they often had no cervix.
The findings raise concerns that older, sicker patients are being screened for diseases that won’t cause them harm over the rest of their lives, raising health-care costs and the potential for unnecessary complications, said Ronald Chen, a senior study author. Doctors and patients should discuss when to use the tests based on life expectancy, which includes age, how functional a person is and health status, he said.
“Cancer screening is a pretty controversial topic these days,” Chen, an assistant professor in the Department of Radiology Oncology at the University of North Carolina at Chapel Hill, said in a telephone interview. “Everyone would agree that patients who have limited life expectancy do not benefit from screening.”
While screenings have saved lives, they can also detect tumors that can lead to invasive biopsies and toxic treatments in people who may never have any symptoms, he said.
“There’s a potential to actually save the health-care system a large amount of money if we stop doing screenings on patients who might not benefit,” Chen said.
Chen said it may be hard for some patients in these circumstances to accept an end to screenings. More studies are needed on how to best measure life expectancy and how to limit testing for patients who may not have long to live, he said.
Millions of cancer screening tests are performed each year. More than 38 million mammograms for breast cancer are done in the U.S. each year, while about 30 million pap tests for cervical cancer were ordered by doctors’ offices in 2010, according to the U.S Food and Drug Administration and the U.S. Center for Disease Control and Prevention.
When screenings should end, depends on which medical advisory group is providing the recommendations.
The U.S. Preventive Services Task Force, an independent medical advisory group to the government, recommends against a prostate screening test for all men, while the American Society of Clinical Oncology and the American Cancer Society suggest stopping once someone is expected to die within 10 years. For breast cancer screening, the Preventive Services Task Force recommends no mammograms starting at 75, while the American College of Radiology suggests stopping when someone is expected to live only another five to seven years.
The researchers in the study looked at rates of screening for cancers of the prostate, breast, cervix and colon in patients ages 65 and older from 2000 to 2010. They used data from the National Health Interview Survey that included 27,404 people. The people were divided into four categories based on their risk of dying in nine years from low -- less than a 25 percent chance -- to very high, classified as a 75 percent or more chance.
Of those who had a very high risk of dying, 41 percent had a colorectal screening in the past five years. For women who had a hysterectomy and were at a very high risk of dying, 34 percent were screened for cervical cancer within the past three years. About half of women who had a hysterectomy and a low or intermediate risk of dying, underwent cervical cancer screenings as well, the researchers found.
The study is the first to look at the screening patterns for all four cancers by life expectancy, the authors said.
Debra Monticciolo, chairwoman of the American College of Radiology’s Quality and Safety Commission, said in a telephone interview that doctors need to consider how the treatment for the cancer they are screening for will affect the patient.
“If someone is too sick to be treated for the condition you are screening them for then it may not be beneficial to put them through the screening,” she said. “Doctors have to look at the whole picture for that individual patient to make a decision.”
A second study released today by the journal found that Medicare patients who got colonoscopies more regularly than recommended -– every five years instead of 10 years -- had a slight reduction in colon cancer-related deaths with increased complications. The findings show that policy makers and doctors should discourage more frequent screening, said the authors from Erasmus University Medical Center in the Netherlands.
“Now we wonder whether screening tests are helping or hurting our patients,” he wrote. “We wonder what harm we may have caused through broad marketing campaigns that strongly promoted screening. It truly will be a new era when providers will be evaluated, in part, by their ability to refrain from ordering cancer screening tests for some of their patients.”
To contact the editors responsible for this story: Reg Gale at firstname.lastname@example.org Andrew Pollack, Angela Zimm