Age to stop?: Appropriate screening in older patients

Roland Grad; Guylène Thériault; Harminder Singh; James A. Dickinson; Olga Szafran; Neil R. Bell

Article Figures & Data

Figures

Tables

Download figure
Open in new tab
Figure 1.
Change in life expectancy at birth in Canada since 1921
Reproduced from Statistics Canada with permission.¹⁴

Tables

Figures

View popup

Table 1.

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

STEPS	ISSUES 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 RECOMMENDATIONS⁸	AGE, Y	ESTIMATES TO FACILITATE SHARED DECISION MAKING^*

		PERCENTILE	LIFE EXPECTANCY, Y	RESIDUAL LIFETIME RISK OF DYING OF BREAST CANCER, DEATHS PER 1000	MORTALITY REDUCTION FOR BREAST CANCER BY SCREENING, DEATHS PER 1000
Breast cancer (for 1000 women)	75	25th	6.8	9	< 1
		50th	11.9	18	3
		Median life expectancy in Canada 13.2 y
No recommendation for women aged ≥ 75 y		75th	17	28	5

	80	25th	4.6	7	NA^†
		50th	8.6	15	2
		Median life expectancy in Canada 10.1 y
		75th	13	24	4

	85	25th	2.9	6	NA^†
		50th	5.9	12	< 1
		Median life expectancy in Canada 7.4 y
		75th	9.6	19	2

B)
TASK FORCE RECOMMENDATIONS⁸	AGE, Y	ESTIMATES TO FACILITATE SHARED DECISION MAKING^*

		PERCENTILE	LIFE EXPECTANCY, Y	RESIDUAL LIFETIME RISK OF DYING OF CERVICAL CANCER, DEATHS PER 10 000	MORTALITY REDUCTION FOR CERVICAL CANCER SCREENING, DEATHS PER 10 000
Cervical cancer (for 10 000 women)	75	25th	6.8	7	1
		50th	11.9	12	4
		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)		75th	17	19	8

	80	25th	4.6	5	NA^†
		50th	8.6	10	3
		Median life expectancy in Canada 10.1 y
		75th	13	15	6

	85	25th	2.9	4	NA^†
		50th	5.9	7	< 1
		Median life expectancy in Canada 7.4 y
		75th	9.6	12	3

C)
TASK FORCE RECOMMENDATIONS⁸	AGE, Y	ESTIMATES TO FACILITATE SHARED DECISION MAKING^*

		PERCENTILE	LIFE EXPECTANCY, Y	RESIDUAL LIFETIME RISK OF DYING OF COLORECTAL CANCER, DEATHS PER 1000	MORTALITY REDUCTION FOR COLORECTAL CANCER SCREENING WITH GUAIAC FOBT, DEATHS PER 1000
Colorectal cancer (for 1000 women or men)	75 (women)	25th	6.8	9	< 1
		50th	11.9	19	2
		Median life expectancy in Canada 13.2 y
We recommend not screening adults aged ≥ 75 y (weak recommendation; low-quality evidence)		75th	17	33	5

	75 (men)	25th	4.9	8	NA^†
		50th	9.3	19	2
		Median life expectancy in Canada 10.2 y
		75th	14.2	35	5

	80 (women)	25th	4.6	8	NA^†
		50th	8.6	18	2
		Median life expectancy in Canada 10.1 y
		75th	13	30	4

	80 (men)	25th	3.3	8	NA^†
		50th	6.7	18	1
		Median life expectancy in Canada 7.7 y
		75th	10.8	32	3

	85 (women)	25th	2.9	8	NA^†
		50th	5.9	16	< 1
		Median life expectancy in Canada 7.4 y
		75th	9.6	25	2

	85 (men)	25th	2.2	8	NA^†
		50th	4.7	16	NA^†
		Median life expectancy in Canada 5.4 y
		75th	7.9	27	2