December 12, 2011 — Adults older than 75 years continue to have regular screenings for colorectal, breast, cervical, and prostate cancer despite guidelines that recommend against such routine screenings in this population, according to a study by Keith M. Bellizzi, MD, MPH, from the University of Connecticut, Storrs, and colleagues. The authors published their results in the December 12/26 issue of the Archives of Internal Medicine.
"Current US Preventive Services Task Force...screening guidelines suggest that there is insufficient evidence to evaluate the mortality benefits of screening men and women older than 75 years and advocate for individualized decisions in this group," Dr. Bellizzi and fellow researchers write. Yet the elevated screening rates the authors found suggest that decisions regarding cancer screening are being made without full knowledge or discussion of the risks and benefits of such tests.
In the study, Dr. Bellizzi and colleagues analyzed data available from the National Health Interview Survey, an annual in-person nationwide survey of about 30,000 households that is used to track health trends in the United States. The researchers included 1697 adults aged 75 to 79 years and 2376 adults older than 80 years in their analysis, derived from a sample of 49,575 patients in the National Health Interview Survey.
Their results showed that 62% of women aged 75 to 79 years and 50% of women aged 80 years and older reported getting a mammogram within the last 2 years. A high percentage of older women also continued to receive regular Papanicolaou tests within the last 3 years: 53% among those women aged 75 to 79 years and 38% among women older than 80 years reported these screenings. Older men and women in the study both reported regular colorectal screenings, including fecal occult blood tests, sigmoidoscopy, or colonoscopy. Fifty-seven percent of those aged 75 to 79 years, and 47% of those older than 80 years, reported undergoing colorectal cancer screenings. Screening rates for prostate cancer using the controversial prostate-specific antigen (PSA) test were also high. The prevalence of a PSA test within the past year was highest among men aged 75 to 79 years (57%), decreasing to 42% after age 80 years.
The most significant predictor for screening was physician recommendation for a particular test. More than 50% of men and women who were older than age 75 years recalled that their physician recommended regular screening. Another strong predictor of screening was education. Although prevalence rates for screening differed by race and ethnicity, these differences disappeared when the authors adjusted for education. Those with low education (without a high school diploma) were significantly less likely to be screened for breast, cervical, colorectal, and prostate cancer when compared with adults older than age 75 years who had a college degree, according to the authors.
The high screening rates found in the study are a concern because increased screenings may subject older adults—who have more comorbidities than younger—to invasive tests. Recommending regular screenings for older adults may also be unwise from an economic standpoint. "In the United States, the number of adults 65 years of older, currently estimated at 36.8 million, is expected to double by the year 2030. Providing high-quality care to this growing population while attempting to contain costs will pose a significant challenge," the authors write.
With increased longevity, older adults can potentially benefit from cancer screening tests, as the incidence of the disease increases with age, noted Louise C. Walter, MD, from the Division of Geriatrics, University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, in an accompanying editorial. Yet older adults are also subject to more harm from invasive procedures after false-positive results from cancer screenings, she notes.
Dr. Walter points out that it's difficult to know whether the screening rates reported in this study are too high, as the risks and benefits of screening are influenced by many patient factors other than age, such as the patient's health status and history of screening. "Still the data by Bellizzi et al raise the issue of whether quality measures should address the overuse of cancer screening. Currently, quality measures in cancer screening focus on increasing screening in persons younger than age 75 years, but what about the problem of overscreening?" Dr. Walter asks.
Rather than focusing on determining the "right" cancer screening rate among adults in older age groups, it would be more useful to assess cancer screening rates among subgroups of older adults who clearly should not receive these tests, such as women who have had a total hysterectomy for benign disease (and thus should not receive Papanicolaou tests) and those with life-limiting illness who are not expected to survive past 5 years, she notes.
Dr. Walter also suggests that future quality measures regarding cancer screenings should provide data on whether older adults engage in an informed decision-making process about cancer screenings with their physician. "While arguments persist about what is the 'right' rate of cancer screening in older persons, it seems clear that the rate of informed decision-making should approach 100%," she writes.
Dr. Bellizzi reported receiving compensation from the National Cancer Institute for the study. Dr. Walter has disclosed no relevant financial relationships.
Arch Intern Med. 2011;171:2031-2038. Abstract
"Current US Preventive Services Task Force...screening guidelines suggest that there is insufficient evidence to evaluate the mortality benefits of screening men and women older than 75 years and advocate for individualized decisions in this group," Dr. Bellizzi and fellow researchers write. Yet the elevated screening rates the authors found suggest that decisions regarding cancer screening are being made without full knowledge or discussion of the risks and benefits of such tests.
In the study, Dr. Bellizzi and colleagues analyzed data available from the National Health Interview Survey, an annual in-person nationwide survey of about 30,000 households that is used to track health trends in the United States. The researchers included 1697 adults aged 75 to 79 years and 2376 adults older than 80 years in their analysis, derived from a sample of 49,575 patients in the National Health Interview Survey.
Their results showed that 62% of women aged 75 to 79 years and 50% of women aged 80 years and older reported getting a mammogram within the last 2 years. A high percentage of older women also continued to receive regular Papanicolaou tests within the last 3 years: 53% among those women aged 75 to 79 years and 38% among women older than 80 years reported these screenings. Older men and women in the study both reported regular colorectal screenings, including fecal occult blood tests, sigmoidoscopy, or colonoscopy. Fifty-seven percent of those aged 75 to 79 years, and 47% of those older than 80 years, reported undergoing colorectal cancer screenings. Screening rates for prostate cancer using the controversial prostate-specific antigen (PSA) test were also high. The prevalence of a PSA test within the past year was highest among men aged 75 to 79 years (57%), decreasing to 42% after age 80 years.
The most significant predictor for screening was physician recommendation for a particular test. More than 50% of men and women who were older than age 75 years recalled that their physician recommended regular screening. Another strong predictor of screening was education. Although prevalence rates for screening differed by race and ethnicity, these differences disappeared when the authors adjusted for education. Those with low education (without a high school diploma) were significantly less likely to be screened for breast, cervical, colorectal, and prostate cancer when compared with adults older than age 75 years who had a college degree, according to the authors.
The high screening rates found in the study are a concern because increased screenings may subject older adults—who have more comorbidities than younger—to invasive tests. Recommending regular screenings for older adults may also be unwise from an economic standpoint. "In the United States, the number of adults 65 years of older, currently estimated at 36.8 million, is expected to double by the year 2030. Providing high-quality care to this growing population while attempting to contain costs will pose a significant challenge," the authors write.
With increased longevity, older adults can potentially benefit from cancer screening tests, as the incidence of the disease increases with age, noted Louise C. Walter, MD, from the Division of Geriatrics, University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, in an accompanying editorial. Yet older adults are also subject to more harm from invasive procedures after false-positive results from cancer screenings, she notes.
Dr. Walter points out that it's difficult to know whether the screening rates reported in this study are too high, as the risks and benefits of screening are influenced by many patient factors other than age, such as the patient's health status and history of screening. "Still the data by Bellizzi et al raise the issue of whether quality measures should address the overuse of cancer screening. Currently, quality measures in cancer screening focus on increasing screening in persons younger than age 75 years, but what about the problem of overscreening?" Dr. Walter asks.
Rather than focusing on determining the "right" cancer screening rate among adults in older age groups, it would be more useful to assess cancer screening rates among subgroups of older adults who clearly should not receive these tests, such as women who have had a total hysterectomy for benign disease (and thus should not receive Papanicolaou tests) and those with life-limiting illness who are not expected to survive past 5 years, she notes.
Dr. Walter also suggests that future quality measures regarding cancer screenings should provide data on whether older adults engage in an informed decision-making process about cancer screenings with their physician. "While arguments persist about what is the 'right' rate of cancer screening in older persons, it seems clear that the rate of informed decision-making should approach 100%," she writes.
Dr. Bellizzi reported receiving compensation from the National Cancer Institute for the study. Dr. Walter has disclosed no relevant financial relationships.
Arch Intern Med. 2011;171:2031-2038. Abstract
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