Too many medical tests may harm, not help, older patients

Yet Elena, who entered a nursing home in November, was screened for breast cancer as recently as that will summer. “If the screening can be not too invasive, why not?” asked her daughter, Dorothy Altemus. “I want her to possess the best quality of life possible.”

although a growing chorus of geriatricians, cancer specialists along with health system analysts are coming forth that has a host of reasons: Such testing inside the nation’s oldest patients can be highly unlikely to detect lethal disease, hugely expensive along with more likely to harm than help since any follow-up testing along with treatment can be often invasive.

along with yet such screening — some have labeled the idea “overdiagnosis” — can be epidemic inside the United States, the result of medical culture, aggressive awareness campaigns along with financial incentives to doctors.

By looking for cancers in people who are unlikely to benefit, “we find something that will wasn’t going to hurt the patient, along with 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 getting regular mammograms, according to the American Journal of Public Health — even though they’re not recommended for people that has a limited life expectancy. along with 55 percent of older men that has 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 along with 80s, cancer screenings often detect slow-growing tumors that will are unlikely to cause problems in patients’ lifetimes. These patients often die of something else — by dementia to heart disease or pneumonia — long before their cancers might ever have become a threat, said Dr. Deborah Korenstein, chief of general internal medicine at brand-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.

“the idea generally takes about 10 years to see benefit by cancer screening, at least in terms of a mortality benefit,” Korenstein said.

Enthusiasm for cancer screenings runs high among patients along with doctors, both of whom tend to overestimate the benefits although 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 inside the past year, according to a 2014 study in JAMA Internal Medicine.
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Even some patients with terminal cancers continue to be screened for different malignancies.

Nine percent of women with advanced cancers — including tumors of the lung, colon or pancreas — received a mammogram along with 6 percent received a cervical cancer screen, 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 along with improve lives for healthy, younger adults, they tend to inflict more harm than not bad in people who are old along with frail, Korenstein said. Testing can lead to anxiety, invasive follow-up procedures along with harsh treatments.

“In patients well into their 80s, with different chronic conditions, the idea’s highly unlikely that will they will receive any benefit by screening, along with more likely that will 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 will don’t need to be found along with treated. Researchers estimate that will up to two-thirds of prostate cancers are overdiagnosed, along with one-third of breast tumors.

“Overdiagnosis can be serious,” Gross said. “the idea’s a tremendous harm that will screening has imposed. … the idea’s something we’re only beginning to reckon with.”

A variety of medical specialties — by the American College of Surgeons to the Society of General Internal Medicine — have advised doctors against screening patients with limited time left. For example, the American Cancer Society recommends prostate along with breast cancer screenings only in patients anticipated to live 10 years or more.
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In November, a coalition of patient advocates, employers along with others included prostate screenings in men over age 75 in its list of the top 5 “low-value” medical procedures. Dr. A. Mark Fendrick, co-director of the coalition, referred to the 5 procedures as “no-brainers,” arguing that will health plans should consider refusing to pay for them.
Prostate cancer screening in men over 75 cost Medicare at least $145 million a year, according to a 2014 study inside the journal Cancer. Mammograms in that will age group cost the federal health plan for seniors more than $410 million a year, according to a 2013 study in JAMA Internal Medicine.

Taxpayers usually foot the bill for these tests, because most seniors are covered by Medicare.

along with while cancer screenings generally aren’t expensive — a mammogram averages about $100 — they can launch a cascade of follow-up tests along with treatments that will add to the total cost of care.
Most spending on unnecessary medical care stems not by rare, big-ticket items, such as heart surgeries, although cheaper services that will are performed much too often, according to an October study in Health Affairs.

A Hard Habit To Break

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

“the idea’s jarring for someone who’s been told every year to get screened along with then at age 75 you tell them to stop,” she said.

John Randall, 78, says he plans to live into his 90s. He sees no reason to skip cancer screening.

“I, for one, do not like to hear what my life expectancy can be,” said Randall, who lives near Madison, Wis. He plans to have his next colonoscopy in January. He feels healthy along with walks 2 miles at a stretch several days a week. “No one knows when I am going to die.”

Will more medical tests make us healthier?
Decades of public awareness campaigns have convinced patients that will cancer screenings are essential, said Dr. Lisa Schwartz, a professor at the Dartmouth Institute for Health Policy along with Clinical Practice. Her research found that will many people see cancer screening as a moral obligation along with can’t imagine a day when they might stop getting screened.

Such campaigns have convinced many women that will “mammograms saves lives.”

although those campaigns don’t mention that will doctors need to screen 1,000 women for a decade in order to prevent one death by breast cancer, said Schonberg.
Yet screenings can have dire consequences. Medical complications during colonoscopies — such as intestinal tears — are almost twice as common in patients ages 75 to 79 compared with those 70 to 74, according to a study published in January 2017 in Annals of Internal Medicine.

Colonoscopies, which require extensive bowel cleansing before the procedure, also can leave many older people dehydrated along with prone to fainting.

PSA tests can lead to prostate biopsies — in which doctors use needles to sample tissue — that will cause infections in about 6 percent of men. These infections send about 1 in 100 men who undergo the procedure to the hospital, according to a 2014 study inside the Journal of Urology.
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Even removing nonfatal skin cancers can cause problems for older patients, said Dr. Eleni Linos, an associate professor at the University of California-San Francisco School of Medicine. Frail patients can struggle to care for surgical wounds along with change dressings; their wounds are also less likely to heal well, Linos said. More than 1 in 4 patients with nonfatal skin cancers report a complication of treatment, Linos’ research shows.

Yet most of the 2.5 million slowest-growing skin cancers found each year are diagnosed in people over 65, according to Linos’ 2014 study. More than 100,000 of these nonfatal skin cancers are treated in patients who die within one year.

Screenings, follow-up tests along with treatments can cause emotional trauma as well.

“For a woman of that will generation who doesn’t possess the cognitive ability to understand what’s going on, having private parts of their body exposed along with pressed against a machine can be very agitating along with upsetting,” Lee said.

Among older women, about 70 percent report significant stress at the time of a biopsy, Schonberg said. Simply lying on a table for a 45-minute biopsy can cause pain for women with significant arthritis, she said.

Virtually all older women with breast cancer wind up getting surgery, which poses additional hardships, Schonberg said. Many are prescribed hormonal therapies that will can cause bone pain, fatigue along with increase the risk of stroke.

Experts reverse themselves on prostate cancer screenings
With prostate cancer, doctors today try to reduce the harm by overdiagnosis by offering men with early-stage disease “active surveillance” instead of immediate treatment. A study published last year inside the brand-new England Journal of Medicine found that will men are just as likely to survive 10 years whether they choose to be treated or monitored.

Jay Schleifer, 74, of Wellington, Fla., was diagnosed that has a low-risk prostate cancer last year. Since then, his doctor has monitored him with additional tests. He’ll be treated only if tests suggest his cancer has become more aggressive.

that will less aggressive approach aims to spare Schleifer by long-term side effects.

Among men who have had prostate cancer surgery, 14 percent lose control of their bladders along with 14 percent develop erectile dysfunction, according to a 2013 study in JAMA Internal Medicine.
In a study published in July inside the Journal of Clinical Oncology, Dr. Richard Hoffman found 15 percent of prostate cancer survivors regretted their treatment decision. Those treated with surgery along with radiation were about twice as likely to regret their choice compared with those who opted to monitor their disease.
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Men are more likely to regret their prostate cancer treatment decisions if they don’t understand the risks beforehand, said Hoffman, director of general internal medicine at the University of Iowa Carver College of Medicine/Iowa City VA Medical Center.

Harold Honeyfield, 87, said he didn’t fully understand the risks when he had prostate cancer surgery 12 years ago. Although he can be glad he was treated, the surgery caused irreversible erectile dysfunction, which has caused stress along with sadness for him along with his wife of 47 years.

“When a man has no erections, that will can be paralysis,” said Honeyfield, of Davis, Calif., who began a support group for different men dealing with prostate cancer. “You’ve lost the ability to be a man.”

A Tough Sell

Doctors have many incentives to continue ordering screening tests as people age.

“the idea’s a lot easier to say, ‘Fine, get your regular mammogram that will year,’ than to possess the much more difficult conversation that will the idea’s not helpful when life expectancy can be limited,” Gross said.

Should there genuinely be a cutoff age for mammograms?

Schonberg said she tries to be diplomatic when talking to patients about halting screening.

“the idea’s hard to tell people, ‘You’re not going to live long enough to benefit,'” Schonberg said. “that will doesn’t go over well.”

Many physicians continue screening older people because they’re afraid they’ll be sued if they miss a cancer, Schonberg said. along with she notes that will some health systems award bonuses to clinicians whose patients have high screening rates.

In addition, “doing less can be perceived as a lack of caring or as ageism,” Schonberg said. “the idea can be uncomfortable for a physician to explain why doing less can be more.”

Doctors should prioritize what they can do to help patients be healthier, said Dr. Louise Walter, chief of geriatrics at the University of California-San Francisco along that has a geriatrician at the San Francisco VA Medical Center. For many older patients, screening for cancer can be not their most pressing need.

“Instead of spending time along with effort on things that will are hurtful along with never going to help them, why not direct time along with energy on things that will will help them live longer along with better?” Walter asked.

For example, Walter might tell a patient, “‘Right at that will point, you have genuinely bad heart failure along with we need to get that will under control,'” Walter said.

different key issues for many older people include preventing falls, treating depression along with alleviating stress in their caregivers, Walter said. Gross said he urges patients to take steps shown to improve their health, such as getting a flu shot or exercising at least 15 minutes a day.

“These are things that will can help them feel better very quickly,” Walter said. “Screenings can take years to have a benefit, if at all.”

Too many medical tests may harm, not help, older patients

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