Should older adults with fewer years to live keep getting cancer screenings? Poll explores attitudes

A majority of older adults disagree with the idea of using life expectancy as part of guidelines that say which patients should get cancer screenings such as mammograms and colonoscopies, a new poll finds.

In all, 62% of people aged 50 to 80 said that national guidelines for stopping cancer-detecting tests in individual patients should not be based on how long that person might have left to live, according to new results from the University of Michigan National Poll on Healthy Aging.

That goes against a trend in such guidelines, which national organizations develop based on medical evidence. Guidelines mainly aim to help health care providers decide when to recommend different tests to a patient—but they also play a role in insurance coverage decisions.

Guidelines have started to factor in life expectancy because the risks from some screening tests increase with age, and because studies show that a person needs to live about 10 years to get the full benefit of finding cancer early.

But the poll finds that even among older adults who can be characterized as "medical minimizers" when it comes to taking action on their own health because they prefer to avoid medical intervention unless it is necessary, a majority (57%) disagreed with the idea of using life expectancy in cancer screening guidelines.

Meanwhile, 70% of all older adults polled don't consider it a problem if some older adults get cancer screenings even when guidelines don't recommend them.

The poll team also asked specifically about the 10-year life expectancy limit, which has already become part of some guidelines. In all, 55% of those polled said it was about right, but 27% said it was too short.

The poll is based at the U-M Institute for Healthcare Policy and Innovation and supported by AARP and Michigan Medicine, the University of Michigan's academic medical center.

"Personalizing cancer screening decisions to each patient's health situation, rather than using one-size-fits-all age cutoffs, could benefit both very healthy and less healthy patients in different ways," said Brian Zikmund-Fisher, Ph.D., a health care decision-making researcher and professor from the U-M School of Public Health who worked on the poll. As a result, he notes, "many guidelines recommend considering the patient's life expectancy."

"But when it comes to a discussion between a health care provider and an individual patient, personalizing the cancer screening decision essentially means talking about how long that person is expected to live," he added. "It also means sometimes deciding that not doing a screening is actually the healthiest approach."

Zikmund-Fisher co-directs the U-M Center for Bioethics and Social Sciences in Medicine, and serves as editor-in-chief of the journals Medical Decision Making and MDM Policy & Practice.

The new findings have special timeliness because of a federal court case that could lead to the end of required insurance coverage for cancer screenings and other preventive care based on national guidelines.

"Right now, insurance plans must cover the cost of cancer screenings for people in the groups covered by guidelines set by the U.S. Preventive Services Task Force," explained poll director Jeffrey Kullgren, M.D., M.P.H., M.S., an associate professor of internal medicine at Michigan Medicine and physician and researcher at the VA Ann Arbor Healthcare System.

"Depending on how the courts eventually rule, insurance coverage of some cancer screenings could end for some older adults, because insurers would be allowed to set their own standards for coverage and not have to abide by guidelines."

In addition, he noted, cancer screening guidelines change if new evidence about who gets the most benefit from them emerges. For instance, a draft USPSTF guideline that may take effect soon lowers the age for the start of screening mammograms to 40, while continuing to find insufficient evidence for screening women over 75.

More poll findings

The poll allowed respondents to say whether they disagreed somewhat, or disagreed strongly, with the idea of screening guidelines using life expectancy. In all 26% strongly disagreed with this. Strong disagreement was more common among women than men (30% vs. 21%) and women were more likely than men to disagree with use of life expectancy in guidelines about both continuing screening (62% vs. 50%) and stopping screening (66% vs. 57%).

Strong disagreement with use of life expectancy in guidelines about stopping screening was also higher among Black poll respondents than among white or Hispanic respondents (37% vs. 24% vs. 28%).

The poll also shows that 74% of white respondents don't see it as a problem if older adults get screened for cancer against the guidelines that apply to them—compared with 61% of Black and 61% of Hispanic respondents. Zikmund-Fisher notes that white, non-Hispanic Americans tend to have the most access to cancer screening to begin with.

The "medical minimizers" group of poll respondents were those who answered that they tend to lean towards waiting and seeing if action is needed when it comes to situations with their own health where the need for action is not clear, and that they tend to lean towards doing only what is necessary in health decisions.

While 57% of this group disagrees with using life expectancy in cancer screening guidelines, it was much lower than the 73% of those characterized as "medical maximizers," but not statistically different from the 62% of those whose answers were somewhere in the middle.

The poll report is based on findings from a nationally representative survey conducted by NORC at the University of Chicago for IHPI and administered online and via phone in January 2023 among 2,563 adults aged 50 to 80. The sample was subsequently weighted to reflect the U.S. population.