Cancer screening burdens elderly patients

December 26, 2017 by Liz Szabo, Kaiser Health News

Elena Altemus is 89 and has dementia. She often forgets her children's names, and sometimes can't recall whether she lives in Maryland or Italy.

Yet Altemus, who entered a nursing home in November, was screened for breast cancer this summer. "If the screening is not too invasive, why not?" said her daughter, Dorothy Altemus. "I want her to have the best quality of life possible."

But a growing number of geriatricians, cancer specialists and health-system analysts say there are many reasons. Such testing in the nation's oldest patients is highly unlikely to detect lethal disease, hugely expensive and more likely to harm than help since any follow-up testing and treatment is often invasive.

And yet such screening is widespread in the United States, the result of medical culture, aggressive awareness campaigns and financial incentives to doctors.

By looking for cancer in people who are unlikely to benefit, "we find something that wasn't going to hurt the patient, and then we hurt the patient," said Dr. Sei Lee, an associate professor of geriatrics at the University of California-San Francisco.

Nearly 1 in 5 women with severe cognitive impairment—including older patients like Elena Altemus—are still get regular mammograms, according to the American Journal of Public Health—even though they're not recommended for people with a limited life expectancy. And 55 percent of older men with a high risk of death over the next decade still get PSA tests for prostate cancer, according to a 2014 study in JAMA Internal Medicine.

Among people in their 70s and 80s, cancer screenings often detect slow-growing tumors that are unlikely to cause problems in patients' lifetimes. Such patients often die of something else long before their cancers would ever have become a threat, said Dr. Deborah Korenstein, chief of general internal medicine at New York's Memorial Sloan Kettering Cancer Center. Prostate cancers, in particular, are often harmless.

Patients with dementia, for example, rarely live longer than a few years.

"It generally takes about 10 years to see benefit from , at least in terms of a mortality benefit," Korenstein said.

Enthusiasm for cancer screenings runs high among patients and doctors, both of whom tend to overestimate the benefits but underappreciate the risks, medical research shows.

In some cases, women are being screened for tumors in organs they no longer have. In a study of women over 30, nearly two-thirds who had undergone a hysterectomy got at least one cervical cancer screening, including one-third who had been screened in the past year, according to a 2014 study in JAMA Internal Medicine.

Even some patients with terminal cancer continue to be screened for other malignancies.

Nine percent of women with advanced cancer—including tumors of the lung, colon or pancreas—received mammograms and 6 percent received cervical cancer screening, according to a 2010 study of Medicare recipients over age 65. Among men on Medicare with incurable cancer, 15 percent were screened for prostate cancer.

Although screenings can extend and improve lives for healthy, younger adults, they tend to inflict more harm than good in people who are old and frail, Korenstein said. Testing can lead to anxiety, invasive follow-up procedures and harsh treatments.

"In patients well into their 80s, with other chronic conditions, it's highly unlikely that they will receive any benefit from screening, and more likely that the harms will outweigh the benefits," said Dr. Cary Gross, a professor at the Yale School of Medicine.

By screening patients near the end of life, doctors often detect tumors that don't need to be found and treated. Researchers estimate that up to two-thirds of are overdiagnosed, as are a third of breast tumors.

"Overdiagnosis is serious," Gross said. "It's a tremendous harm that screening has imposed. ... It's something we're only beginning to reckon with."

A variety of medical specialties—from the American College of Surgeons to the Society of General Internal Medicine—have advised doctors against screening patients with limited time to live.. For example, the American Cancer Society recommends prostate and breast cancer screenings only in patients expected to live 10 years or more.

In November, a coalition of patient advocates, employers and others included prostate screenings in men over age 75 in its list of the top five "low-value" medical procedures. Dr. A. Mark Fendrick, co-director of the coalition, referred to the five procedures as "no-brainers," arguing that health plans should consider refusing to pay for them.

Prostate cancer in men over 75 cost Medicare at least $145 million a year, according to a 2014 study in the journal Cancer. Mammograms in this age group cost the federal health plan for seniors more than $410 million a year, according to a 2013 study in JAMA Internal Medicine.

And while screenings generally aren't expensive—a mammogram averages about $100—they can begin a series of follow-up tests and treatments that add to the total cost of care.

Most spending on unnecessary medical care stems not from rare, big-ticket items, such as heart surgeries, but cheaper services that are performed much too often, according to an October study in Health Affairs.

Many older expect to continue getting screened, said Dr. Mara Schonberg, an associate professor at Harvard Medical School and Boston's Beth Israel Deaconess Medical Center.

"It's jarring for someone who's been told every year to get screened and then at age 75 you tell them to stop," she said.

Explore further: Abbreviated breast MRI may be additional screening option for dense breasts

Related Stories

Abbreviated breast MRI may be additional screening option for dense breasts

November 28, 2017
Among women with dense breast tissue, for whom traditional mammograms are less effective at detecting cancer, who request additional screening after a negative mammogram, abbreviated breast MRI (AB-MR) may be a valuable cancer ...

Nonrecommended screenings for prostate, breast cancer in older individuals

January 21, 2016
An estimated 15.7 percent of individuals 65 or older may have received nonrecommended screenings for prostate and breast cancers because they had limited life expectancies of less than 10 years, according to an article published ...

What men should know about new prostate cancer screening guidelines

April 17, 2017
Men ages 55 to 69 should talk with their health care provider about prostate-specific antigen (PSA)-based screening for prostate cancer. That's according to new recommendations from the U.S. Preventive Services Task Force.

Breast cancer screening associated with substantial overdiagnosis in Danish study

January 9, 2017
Breast cancer screening in Denmark was associated with a substantial increase in the incidence of nonadvanced tumors and DCIS but not with a reduction in the incidence of advanced tumors. The rate of overdiagnosis was also ...

High Medicare spending on prostate cancer screenings, but little benefit for older men

October 4, 2013
Prostate cancer screening has little benefit for men aged 75 and older, yet over three years, the Medicare fee-for-service program spent $447 million annually on PSA-based screenings—one-third of which was for men in the ...

Public not being informed about dangers of medical overdiagnosis

May 20, 2015
A national survey reveals that only one in ten Australians report being told about the risk of overdiagnosis by their doctors, according to research published today in the scientific journal PLOS ONE.

Recommended for you

Single blood test screens for eight cancer types

January 18, 2018
Johns Hopkins Kimmel Cancer Center researchers developed a single blood test that screens for eight common cancer types and helps identify the location of the cancer.

These foods may up your odds for colon cancer

January 18, 2018
(HealthDay)—Chowing down on red meat, white bread and sugar-laden drinks might increase your long-term risk of colon cancer, a new study suggests.

How cancer metastasis happens: Researchers reveal a key mechanism

January 18, 2018
Cancer metastasis, the migration of cells from a primary tumor to form distant tumors in the body, can be triggered by a chronic leakage of DNA within tumor cells, according to a team led by Weill Cornell Medicine and Memorial ...

Researchers find a way to 'starve' cancer

January 18, 2018
Researchers at Vanderbilt University Medical Center (VUMC) have demonstrated for the first time that it is possible to starve a tumor and stop its growth with a newly discovered small compound that blocks uptake of the vital ...

Modular gene enhancer promotes leukemia and regulates effectiveness of chemotherapy

January 18, 2018
Every day, billions of new blood cells are generated in the bone marrow. The gene Myc is known to play an important role in this process, and is also known to play a role in cancer. Scientists from the German Cancer Research ...

Presurgical targeted therapy delays relapse of high-risk stage 3 melanoma

January 17, 2018
A pair of targeted therapies given before and after surgery for melanoma produced at least a six-fold increase in time to progression compared to standard-of-care surgery for patients with stage 3 disease, researchers at ...

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.