Analyses of data from 27,404 people aged 65 and older participating in the National Health Interview Survey (NHIS) from 2000 through 2010 suggest that overscreening for prostate, breast, cervical, and colorectal cancer screening “is common in both men and women, which not only increases health care expenditure but can lead to net patient harm.” The study by Trevor J. Royce, MD, MS, and colleagues at the University of North Carolina at Chapel Hill, was published in JAMA Internal Medicine.
Screening Reconsidered
“There is general agreement that routine cancer screening has little likelihood to result in a net benefit for individuals with limited life expectancy, as reflected in the consistency in existing guidelines,” the authors wrote. As an example, they cited ASCO’s Choosing Wisely Campaign and its recommendation to avoid prostate-specific antigen (PSA) screening in men with less than a 10-year life expectancy, as well as similar recommendations from the American Cancer Society and the American Urological Association. Recommendations against screening for breast, cervical, and colorectal cancer are also based on age and limited life expectancy.
Using a validated mortality index specific for NHIS, participants were grouped into those with low (< 25%), intermediate (25%–49%), high (50%–74%), and very high (≥ 75%) risks of 9-year mortality. While groups of individuals with very high risks or mortality (lower life expectancy) had lower rates of screening, a large proportion of the U.S. population with less than a 9-year life expectancy (≥ 75% mortality risk) received cancer screening, including 55% in the group who received prostate cancer screening, the investigators noted. “For women who had a hysterectomy for benign reasons, 34% to 56% had a Papanicolaou test within the past 3 years,” they added.
Overall, 31% to 55% of participants with very high mortality risk received recent cancer screening. Screening for prostate and cervical cancers occurred less frequently in more recent years compared with 2000. Data on screening came from self-reporting by study participants.
The authors commented:
Our results highlight the challenges to implementing evidence-based screening guidelines on a population level. While the lack of net benefit from cancer screening in individuals with limited life expectancy is widely recognized and publicized in clinical practice guidelines, important obstacles exist to reliably applying these guidelines clinically. One such obstacle is the lack of a readily available and easy-to-use clinical tool to accurately assess life expectancy for each patient. Without simple and reliable ways to assess 10-year life expectancy in the clinic, guidelines may be impractical for clinical adherence, which may partially explain the findings of this study. Furthermore, even when limited life expectancy is recognized, the physician may have difficulty communicating this prognosis and/or the patient may have difficulty accepting a limited life expectancy or cessation of screening. The practice of defensive medicine and fear of litigation may further contribute to overscreening.
A related study in the same issue of JAMA Internal Medicine used microsimulation modeling to determine whether colonoscopy screening at 5 or 3 years, rather than 10, for Medicare beneficiaries who had a negative result at age 55, or continuing screening until 85 or 95 years results in net benefit to individuals at average risk of colorectal cancer and average life expectancy. The answer was no.
In almost all cases, more intensive screening resulted in a loss of quality-adjusted life-years, a net harm, according to Frank van Hees, MSc, of Erasmus University in Rotterdam, the Netherlands, and colleagues. “Screening Medicare beneficiaries more intensively than recommended is not only inefficient from a societal perspective; often it is also unfavorable for those being screened. This study provides evidence and a clear rationale for clinicians and policy makers to actively discourage this practice,” the investigators stated.
Three Recommendations
In an editorial commenting on both articles, Cary P. Gross, MD, of Yale University School of Medicine, New Haven, stated that it “is particularly important to question screening strategies for older persons,” not only because of their shorter life expectancies, but because of higher risk of complications from procedures such as colonoscopy. Dr. Gross offered three steps “that can help to allay skepticism about cancer screening tests for older persons, so that we can have confidence that these efforts are benefiting patients and not causing harm.”
He continued, “First, clinicians should alter their approach to discussing cancer screening with older persons.” Decisions about screening should take into account individual differences in life expectancy. “Clinicians and patients should work together to design and evaluate informational tools that can help inform patients about anticipated benefits and harms given their individual risk.”
“Second, Medicare payment policies warrant closer scrutiny.” Clinicians and patient advocates could help the Centers for Medicare & Medicaid Services (CMS) “identify clinical scenarios in which screening is neither reasonable nor necessary.” In addition, CMS should adhere to its own screening-related reimbursement policies and not pay for screening at shorter than recommended intervals.
“Third, quality measures should address overscreening, including for cancer care,” after years of focusing on increasing screening use. “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,” Dr. Gross concluded. ■
Royce TJ, et al: JAMA Intern Med. August 18, 2014 (early release online).
Van Hees F, et al: JAMA Intern Med. August 18, 2014 (early release online).
Gross CP: JAMA Intern Med. August 18, 2014 (early release online).
