Cancer Screening in Elderly Patients: A Framework for Individualized Decision Making
TL;DR: A framework to guide individualized cancer screening decisions in older patients may be more useful to the practicing clinician than age guidelines because it anchors decisions through quantitative estimates of life expectancy, risk of cancer death, and screening outcomes based on published data.
Abstract: Considerable uncertainty exists about the use of cancer screening tests in older people, as illustrated by the different age cutoffs recommended by various guideline panels. We suggest that a framework to guide individualized cancer screening decisions in older patients may be more useful to the practicing clinician than age guidelines. Like many medical decisions, cancer screening decisions require weighing quantitative information, such as risk of cancer death and likelihood of beneficial and adverse screening outcomes, as well as qualitative factors, such as individual patients' values and preferences. Our framework first anchors decisions through quantitative estimates of life expectancy, risk of cancer death, and screening outcomes based on published data. Potential benefits of screening are presented as the number needed to screen to prevent 1 cancer-specific death, based on the estimated life expectancy during which a patient will be screened. Estimates reveal substantial variability in the likelihood of benefit for patients of similar ages with varying life expectancies. In fact, patients with life expectancies of less than 5 years are unlikely to derive any survival benefit from cancer screening. We also consider the likelihood of potential harm from screening according to patient factors and test characteristics. Some of the greatest harms of screening occur by detecting cancers that would never have become clinically significant. This becomes more likely as life expectancy decreases. Finally, since many cancer screening decisions in older adults cannot be answered solely by quantitative estimates of benefits and harms, considering the estimated outcomes according to the patient's own values and preferences is the final step for making informed screening decisions.
Citations
More filters
TL;DR: It is suggested that adhering to current CPGs in caring for an older person with several comorbidities may have undesirable effects and could create perverse incentives that emphasize the wrong aspects of care for this population and diminish the quality of their care.
Abstract: ContextClinical practice guidelines (CPGs) have been developed to improve the
quality of health care for many chronic conditions. Pay-for-performance initiatives
assess physician adherence to interventions that may reflect CPG recommendations.ObjectiveTo evaluate the applicability of CPGs to the care of older individuals
with several comorbid diseases.Data SourcesThe National Health Interview Survey and a nationally representative
sample of Medicare beneficiaries (to identify the most prevalent chronic diseases
in this population); the National Guideline Clearinghouse (for locating evidence-based
CPGs for each chronic disease).Study SelectionOf the 15 most common chronic diseases, we selected hypertension, chronic
heart failure, stable angina, atrial fibrillation, hypercholesterolemia, diabetes
mellitus, osteoarthritis, chronic obstructive pulmonary disease, and osteoporosis,
which are usually managed in primary care, choosing CPGs promulgated by national
and international medical organizations for each.Data ExtractionTwo investigators independently assessed whether each CPG addressed
older patients with multiple comorbid diseases, goals of treatment, interactions
between recommendations, burden to patients and caregivers, patient preferences,
life expectancy, and quality of life. Differences were resolved by consensus.
For a hypothetical 79-year-old woman with chronic obstructive pulmonary disease,
type 2 diabetes, osteoporosis, hypertension, and osteoarthritis, we aggregated
the recommendations from the relevant CPGs.Data SynthesisMost CPGs did not modify or discuss the applicability of their recommendations
for older patients with multiple comorbidities. Most also did not comment
on burden, short- and long-term goals, and the quality of the underlying scientific
evidence, nor give guidance for incorporating patient preferences into treatment
plans. If the relevant CPGs were followed, the hypothetical patient would
be prescribed 12 medications (costing her $406 per month) and a complicated
nonpharmacological regimen. Adverse interactions between drugs and diseases
could result.ConclusionsThis review suggests that adhering to current CPGs in caring for an
older person with several comorbidities may have undesirable effects. Basing
standards for quality of care and pay for performance on existing CPGs could
lead to inappropriate judgment of the care provided to older individuals with
complex comorbidities and could create perverse incentives that emphasize
the wrong aspects of care for this population and diminish the quality of
their care. Developing measures of the quality of the care needed by older
patients with complex comorbidities is critical to improving their care.
2,247 citations
Cites background from "Cancer Screening in Elderly Patient..."
...We examined the concepts of competing risks and burden of treatment for patients and caregivers because these issues are central in the care of older adults with multiple diseases.(49,50) Two investigators (C....
[...]
...efit of an intervention for a target disease.(49) Future CPGs that address how to incorporate quality of life and the risks, benefits, and burden of recommended treatments for older adults with comor-...
[...]
...corporated into quality-of-care standards in pay-for-performance initiatives.(49,68,72)...
[...]
01 Jan 2014
TL;DR: Lymphedema is a common complication after treatment for breast cancer and factors associated with increased risk of lymphedEMA include extent of axillary surgery, axillary radiation, infection, and patient obesity.
1,988 citations
Katholieke Universiteit Leuven1, University of Sheffield2, Medical University of Vienna3, Charité4, University of Bologna5, Vita-Salute San Raffaele University6, University of Manchester7, University of Lugano8, Netherlands Cancer Institute9, Monash University10, St James's University Hospital11, Erasmus University Medical Center12, Aberdeen Royal Infirmary13, University of Aberdeen14, Wrightington, Wigan and Leigh NHS Foundation Trust15, Cardiff University16, University of Amsterdam17, University of Lyon18, Utrecht University19, University of Liverpool20
TL;DR: The 2020 EAU-EANM-ESTRO-ESUR-SIOG guidelines on PCa guidelines summarise the most recent findings and advice for their use in clinical practice and include a strong recommendation to consider moderate hypofractionation in intermediate-risk patients.
1,369 citations
Memorial Sloan Kettering Cancer Center1, Louisiana State University2, Fred Hutchinson Cancer Research Center3, Harvard University4, University of Texas MD Anderson Cancer Center5, University of California, San Francisco6, University of Minnesota7, Emory University8, University of Virginia9, American Cancer Society10
TL;DR: The updated ACS guidelines for breast cancer screening for women at average risk of breast cancer provide evidence-based recommendations and should be considered by physicians and women in discussions about breast cancer Screening.
Abstract: Importance Breast cancer is a leading cause of premature mortality among US women. Early detection has been shown to be associated with reduced breast cancer morbidity and mortality. Objective To update the American Cancer Society (ACS) 2003 breast cancer screening guideline for women at average risk for breast cancer. Process The ACS commissioned a systematic evidence review of the breast cancer screening literature to inform the update and a supplemental analysis of mammography registry data to address questions related to the screening interval. Formulation of recommendations was based on the quality of the evidence and judgment (incorporating values and preferences) about the balance of benefits and harms. Evidence Synthesis Screening mammography in women aged 40 to 69 years is associated with a reduction in breast cancer deaths across a range of study designs, and inferential evidence supports breast cancer screening for women 70 years and older who are in good health. Estimates of the cumulative lifetime risk of false-positive examination results are greater if screening begins at younger ages because of the greater number of mammograms, as well as the higher recall rate in younger women. The quality of the evidence for overdiagnosis is not sufficient to estimate a lifetime risk with confidence. Analysis examining the screening interval demonstrates more favorable tumor characteristics when premenopausal women are screened annually vs biennially. Evidence does not support routine clinical breast examination as a screening method for women at average risk. Recommendations The ACS recommends that women with an average risk of breast cancer should undergo regular screening mammography starting at age 45 years (strong recommendation). Women aged 45 to 54 years should be screened annually (qualified recommendation). Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually (qualified recommendation). Women should have the opportunity to begin annual screening between the ages of 40 and 44 years (qualified recommendation). Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer (qualified recommendation). The ACS does not recommend clinical breast examination for breast cancer screening among average-risk women at any age (qualified recommendation). Conclusions and Relevance These updated ACS guidelines provide evidence-based recommendations for breast cancer screening for women at average risk of breast cancer. These recommendations should be considered by physicians and women in discussions about breast cancer screening.
1,244 citations
TL;DR: In the community, mammography remains the main screening tool while the effectiveness of clinical breast examination and self-examination are less, and new screening modalities are unlikely to replace mammography in the near future for screening the general population.
Abstract: ContextBreast cancer screening in community practices may be different from
that in randomized controlled trials. New screening modalities are becoming
available.ObjectivesTo review breast cancer screening, especially in the community and to
examine evidence about new screening modalities.Data Sources and Study SelectionEnglish-language articles of randomized controlled trials assessing
effectiveness of breast cancer screening were reviewed, as well as meta-analyses,
systematic reviews, studies of breast cancer screening in the community, and
guidelines. Also, studies of newer screening modalities were assessed.Data SynthesisAll major US medical organizations recommend screening mammography for
women aged 40 years and older. Screening mammography reduces breast cancer
mortality by about 20% to 35% in women aged 50 to 69 years and slightly less
in women aged 40 to 49 years at 14 years of follow-up. Approximately 95% of
women with abnormalities on screening mammograms do not have breast cancer
with variability based on such factors as age of the woman and assessment
category assigned by the radiologist. Studies comparing full-field digital
mammography to screen film have not shown statistically significant differences
in cancer detection while the impact on recall rates (percentage of screening
mammograms considered to have positive results) was unclear. One study suggested
that computer-aided detection increases cancer detection rates and recall
rates while a second larger study did not find any significant differences.
Screening clinical breast examination detects some cancers missed by mammography,
but the sensitivity reported in the community is lower (28% to 36%) than in
randomized trials (about 54%). Breast self-examination has not been shown
to be effective in reducing breast cancer mortality, but it does increase
the number of breast biopsies performed because of false-positives. Magnetic
resonance imaging and ultrasound are being studied for screening women at
high risk for breast cancer but are not recommended for screening the general
population. Sensitivity of magnetic resonance imaging in high-risk women has
been found to be much higher than that of mammography but specificity is generally
lower. Effect of the magnetic resonance imaging on breast cancer mortality
is not known. A balanced discussion of possible benefits and harms of screening
should be undertaken with each woman.ConclusionsIn the community, mammography remains the main screening tool while
the effectiveness of clinical breast examination and self-examination are
less. New screening modalities are unlikely to replace mammography in the
near future for screening the general population.
990 citations
References
More filters
Journal Article•
[...]
TL;DR: The Joint UNECE/Eurostat/OECD Working Group on Statistics for Sustainable Development (WGSSD) was commissioned by the CES in 2005 to develop a broad conceptual framework for measuring sustainable development based on the capital approach, and to identify a small set of indicators that could serve for international comparisons.
Abstract: 1. The Joint UNECE/Eurostat/OECD Working Group on Statistics for Sustainable Development (WGSSD) was commissioned by the CES in 2005 to develop a broad conceptual framework for measuring sustainable development based on the capital approach, and to identify a small set of indicators that could serve for international comparisons. As a result of its two years of work, the WGSSD prepared a Report on Measuring Sustainable Development. The WGSSD noted in the Report the need for further conceptual and methodological development to refine certain elements of the capital approach. The final version of the Report will be made available before the end of 2008. A print version is expected to be available by March 2009. With the finalization of this Report, the mandate of the WGSSD is fulfilled. 2. In February 2008, the CES Bureau reviewed the Report and recognized that many issues remain unresolved and can be further developed. The Bureau agreed on a proposal that a new Task Force be created. The proposal was presented to the plenary session of the CES in June 2008. The CES expressed general support for continuing the work in this area and recommended that the Bureau discuss how to proceed further at its October 2008 meeting. 3. In October 2008, the CES Bureau reviewed the first draft version of the Terms of Reference and provided a more detailed guidance on the work of a future Task Force. The Bureau made the following main recommendations: (a) The indicators should be useful for policy makers and should allow comparison across time; (b) The refinement of the small set of capital indicators should continue; (c) The areas of social and human capital should be further developed.
4,250 citations
"Cancer Screening in Elderly Patient..." refers background in this paper
...However, the actual likelihood of benefit from screening will always be substantially less than this value, since screening may miss early-stage malignancies, detect disease too advanced or aggressive to respond to treatment, or detect indolent cancers that are not likely to produce clinical symptoms.(1) Even screening, effective in early detection, may not benefit patients with short life expectancies since the benefit from screening is not immediate....
[...]
...CURRENTLY CONSIDERABLE UNcertainty exists about the best use of cancer screening tests in older people.(1) Part of this stems from a lack of randomized controlled trials of screening interventions that have included patients older than 75 years....
[...]
Book•
01 Jan 1985
TL;DR: Clinical Epidemiology is a book dedicated to H.L. Mencken, Kurt Vonnegut, Jr., Douglas Adams, and the Emperor's New Clothes and Physicians and others who wish to recognize key clinical epidemiologic features of the diagnosis and management of patients will benefit from reading.
Abstract: I might have guessed that a book dedicated to "H.L. Mencken, Kurt Vonnegut, Jr., Douglas Adams, and the Emperor's New Clothes" would be fun to read. It was! Readers will sense the authors' enthusiasm for their subject on each page, from the preface to the final chapter. The authors prepared this book for "users" rather than "doers" of clinical research. Physicians and others who wish to recognize key clinical epidemiologic features of the diagnosis and management of patients will benefit from reading Clinical Epidemiology. Those who wish to conduct actual research studies will need to look elsewhere for a detailed discussion of clinical epidemiologic methodology. In this review, I will mention
3,791 citations
"Cancer Screening in Elderly Patient..." refers background in this paper
...The absolute benefit of a screening test can be conveyed by the absolute risk reduction(theabsolutedifference inproportions of patients with a given outcome from 2 treatments or actions), or more effectively by calculating the numberneeded to screen(NNS),which is the reciprocal of the absolute risk reduction.(26,27) Considering patients at average risk for developing a screened cancer, the approximate NNS to prevent 1 cancer-specific death is listed inTABLE 2 for screening tests that have been shown to be effective in reducing cancerspecific mortality....
[...]
TL;DR: Cutting mortality in the annually screened group was accompanied by improved survival in those with colorectal cancer and a shift to detection at an earlier stage of cancer.
Abstract: Background Although tests for occult blood in the feces are widely used to screen for colorectal cancers, there is no conclusive evidence that they reduce mortality from this cause. We evaluated a fecal occult-blood test in a randomized trial and documented its effectiveness. Methods We randomly assigned 46,551 participants 50 to 80 years of age to screening for colorectal cancer once a year, to screening every two years, or to a control group. Participants who were screened submitted six guaiac-impregnated paper slides with two smears from each of three consecutive stools. About 83 percent of the slides were rehydrated. Participants who tested positive underwent a diagnostic evaluation that included colonoscopy. Vital status was ascertained for all participants over 13 years of follow-up. A committee determined causes of death. A single pathologist determined the stage of cancer for each tissue specimen. Differences in mortality from colorectal cancer, the primary study end point, were monitored with the...
3,199 citations
TL;DR: Evidence from this study and other trials suggest that consideration should be given to a national programme of FOB screening to reduce CRC mortality in the general population.
2,778 citations
TL;DR: The findings indicate that biennial screening by FOB tests can reduce CRC mortality, and the effect of the removal of more precursor adenomas in the screening-group participants than in controls on CRC incidence.
2,494 citations