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OtherPractice

Age to stop?

Appropriate screening in older patients

Roland Grad, Guylène Thériault, Harminder Singh, James A. Dickinson, Olga Szafran and Neil R. Bell
Canadian Family Physician August 2019; 65 (8) 543-548;
Roland Grad
Associate Professor in the Department of Family Medicine at McGill University in Montreal, Que.
MD CM MSc CCFP FCFP
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  • For correspondence: roland.grad@mcgill.ca
Guylène Thériault
Associate Vice Dean of Distributed Medical Education and Academic Lead for the Physicianship Component at Outaouais Medical Campus in the Faculty of Medicine at McGill University.
MD CCFP
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Harminder Singh
Associate Professor in the Department of Internal Medicine and the Department of Community Health Sciences at the University of Manitoba in Winnipeg and in the Department of Hematology and Oncology of CancerCare Manitoba.
MD MPH FRCPC
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James A. Dickinson
Professor in the Department of Family Medicine and the Department of Community Health Sciences at the University of Calgary in Alberta.
MB BS PhD CCFP FRACGP
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Olga Szafran
Associate Director of Research in the Department of Family Medicine at the University of Alberta in Edmonton.
MHSA
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Neil R. Bell
Professor in the Department of Family Medicine at the University of Alberta.
MD SM CCFP FCFP
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    Figure 1.

    Change in life expectancy at birth in Canada since 1921

    Reproduced from Statistics Canada with permission.14

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    Table 1.

    Steps for consideration and discussion when deciding if your older patient would benefit from screening

    STEPSISSUES FOR CONSIDERATION
    Determining whether to discuss screening with older patients
    • Requests for continued screening will come from patients or relatives

    • Omitting discussion about cancer screening is not preferred by older patients1

    • Family physicians should be prepared to discuss screening decisions with older patients

    • Older patients might be confused about the difference between screening and monitoring of existing health conditions

    Clinical practice guidelines often recommend against screening in older patients based on a specific age or life expectancy

    Clinical trials on screening used to develop practice guidelines do not typically include people aged > 75 y
    Determining if older patients might benefit from screening
    • Patient life expectancy is an important consideration in deciding on the potential benefits and harms of screening

    • Family physicians should estimate individual life expectancy based on unique patient circumstances to aid in decision making on screening

    • Older patients will have a range of life expectancies depending on comorbidity.6 Each age group will include patients who might or might not benefit from screening (Table 2)7–9

    • Other issues that should be considered include health status, frailty,4 and individual patient values and preferences

    Benefits from screening occur downstream while harms typically occur immediately after screening

    Patients with life expectancy > 5–10 y have the potential to benefit from some screening interventions
    Discussing screening
    • Some older patients might not consider life expectancy an important issue and might prefer not to have a discussion on screening framed by their life expectancy—although all of us older than 50 are aware that no one gets out of here alive!

    • Use of health status is a preferred approach to framing discussions about screening in older patients

    Appropriate framing of discussions is important in developing individualized screening decisions (Box 1)10
    Identifying patients who would probably not benefit from screening
    • The most preferred explanation is a priority shift to other health care issues. Consider this script: “Your other health issues should take priority. This test is unlikely to help you live longer or better”

    • Confidence in their physician is an important factor in patients’ acceptance of recommendations to stop screening

    Decision aids that explain the benefits and risks of screening in a manner more easily understood by patients (using absolute risk and natural frequencies) can be used to support shared decision making
    Identifying patients who have the potential to benefit from screening
    • Patients should be aware of the lack of evidence to support the benefits of screening into advanced age

    • Discussions should include both the potential harms and benefits of any screening intervention

    • Patients should be informed about the implications of positive test results, such as further tests or interventions that could cause harm

    • View popup
    Table 2.

    Estimates of life expectancy and mortality reduction from cancer screening at ages 75, 80, and 85 y: A) Breast, B) cervical, and C) colorectal cancer.

    A)
    TASK FORCE RECOMMENDATIONS8AGE, YESTIMATES TO FACILITATE SHARED DECISION MAKING*
    PERCENTILELIFE EXPECTANCY, YRESIDUAL LIFETIME RISK OF DYING OF BREAST CANCER, DEATHS PER 1000MORTALITY REDUCTION FOR BREAST CANCER BY SCREENING, DEATHS PER 1000
    Breast cancer (for 1000 women)7525th6.89< 1
    50th11.9183
    Median life expectancy in Canada 13.2 y
    No recommendation for women aged ≥ 75 y75th17285
    8025th4.67NA†
    50th8.6152
    Median life expectancy in Canada 10.1 y
    75th13244
    8525th2.96NA†
    50th5.912< 1
    Median life expectancy in Canada 7.4 y
    75th9.6192
    B)
    TASK FORCE RECOMMENDATIONS8AGE, YESTIMATES TO FACILITATE SHARED DECISION MAKING*
    PERCENTILELIFE EXPECTANCY, YRESIDUAL LIFETIME RISK OF DYING OF CERVICAL CANCER, DEATHS PER 10 000MORTALITY REDUCTION FOR CERVICAL CANCER SCREENING, DEATHS PER 10 000
    Cervical cancer (for 10 000 women)7525th6.871
    50th11.9124
    Median life expectancy in Canada 13.2 y
    For women aged ≥ 70 y who have been adequately screened we recommend that routine screening cease (weak recommendation; low-quality evidence)75th17198
    8025th4.65NA†
    50th8.6103
    Median life expectancy in Canada 10.1 y
    75th13156
    8525th2.94NA†
    50th5.97< 1
    Median life expectancy in Canada 7.4 y
    75th9.6123
    C)
    TASK FORCE RECOMMENDATIONS8AGE, YESTIMATES TO FACILITATE SHARED DECISION MAKING*
    PERCENTILELIFE EXPECTANCY, YRESIDUAL LIFETIME RISK OF DYING OF COLORECTAL CANCER, DEATHS PER 1000MORTALITY REDUCTION FOR COLORECTAL CANCER SCREENING WITH GUAIAC FOBT, DEATHS PER 1000
    Colorectal cancer (for 1000 women or men)75 (women)25th6.89< 1
    50th11.9192
    Median life expectancy in Canada 13.2 y
    We recommend not screening adults aged ≥ 75 y (weak recommendation; low-quality evidence)75th17335
    75 (men)25th4.98NA†
    50th9.3192
    Median life expectancy in Canada 10.2 y
    75th14.2355
    80 (women)25th4.68NA†
    50th8.6182
    Median life expectancy in Canada 10.1 y
    75th13304
    80 (men)25th3.38NA†
    50th6.7181
    Median life expectancy in Canada 7.7 y
    75th10.8323
    85 (women)25th2.98NA†
    50th5.916< 1
    Median life expectancy in Canada 7.4 y
    75th9.6252
    85 (men)25th2.28NA†
    50th4.716NA†
    Median life expectancy in Canada 5.4 y
    75th7.9272
    • FOBT—fecal occult blood test, NA—not applicable.

    • ↵* Adapted from Statistics Canada9 and Walter and Covinsky.7

    • ↵† No mortality reduction is expected.

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Canadian Family Physician: 65 (8)
Canadian Family Physician
Vol. 65, Issue 8
1 Aug 2019
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Age to stop?
Roland Grad, Guylène Thériault, Harminder Singh, James A. Dickinson, Olga Szafran, Neil R. Bell
Canadian Family Physician Aug 2019, 65 (8) 543-548;

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  • Article
    • Case description
    • Deciding if an older patient would benefit from screening
    • Overscreening
    • Life expectancy
    • Downstream thinking about the possible outcomes of screening
    • Shared decision making and patient values and preferences
    • Framing the discussion on screening in older patients
    • And in the end …
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  • Evaluer les nouveaux tests de depistage: Une panacee ou du gaspillage?
  • Que devraient enseigner les educateurs pour ameliorer les soins de sante preventifs?
  • What should educators teach to improve preventive health care?
  • Faut-il partager ou non?: Quand la decision partagee est-elle la meilleure option?
  • To share or not to share: When is shared decision making the best option?
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