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Comorbid conditions determined appropriate age for cancer screening cessation
Models that account for individuals’ comorbid conditions may help determine the age at which they should stop undergoing breast, prostate and colorectal cancer screenings, according to study results.
“The presence of other illnesses should inform decisions about when to stop screening older people for cancer,” Iris Lansdorp-Vogelaar, PhD, of the department of public health at Erasmus University Medical Center in the Netherlands, told HemOnc Today. “At the same age, the trade-off for harms and benefits of screening is very different for people with no comorbidities compared to people with severe comorbidities, and this trade-off should be taken into account when making decisions about screening cessation.”
Lansdorp-Vogelaar and colleagues used seven cancer simulation models to estimate the benefits and harms of cancer screening based on age and comorbid conditions.
In their modeling study, they used data from cohorts of hypothetical US adults aged 66 to 90 years in 2010. All individuals either were in average health or were classified as having one of four levels of comorbid conditions: none, mild, moderate or severe.
These adults were followed for their lifetimes and compared with simulated cohorts of adults with an average life expectancy aged 74 to 76 years, or the ages for which the US Preventive Services Task Force recommends the cessation of routine screenings.
Researchers first calculated the harms — such as overdiagnosis or false-positive test results — and benefits of screening across comorbid condition levels according to age.
Results showed 132 to 173 women aged 74 years would need to undergo breast cancer screening to gain 1 life-year. The range increased (146 to 198) when researchers calculated the number of women aged 76 years or older who would need to undergo screening to gain 1 life-year.
The number needed to screen to gain 1 life-year also increased with age for prostate cancer screening, (74 years, 150 to 165 men; 76 years, 159 to 197 men) and colorectal cancer screening (74 years, 161 to 229 adults; 75 years, 182 to 272 adults).
Researchers then used simulation studies to evaluate the harms and benefits of screening according to comorbidities, calculating the age at which individuals would have a similar screening risk–benefit ratio as a person aged 74 years in average health.
Those ages — consistent for mammography, PSA testing and fecal immunochemical testing — were 76 years for those with no comorbid conditions, 74 years for those with mild comorbid conditions, 72 years for those with moderate comorbid conditions, and 66 years for those with severe comorbid conditions.
“The results across models and cancer sites were very robust and strongly suggest that the age of screening cessation based on comorbid conditions varies by nearly a 10-year interval around the age cut point of 74 years included in current recommendations on breast and colorectal cancer screening,” Lansdorp-Vogelaar and colleagues wrote. “Our data on common chronic health conditions and their associated comorbid condition level, together with model projections of screening benefits and harms at each of these comorbid conditions levels, can inform discussions between providers and their older patients about personalizing decisions regarding when to stop cancer screening.”
Disclosure: See the study for a full list of the researchers’ relevant financial disclosures.
Perspective
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The benefits of cancer screening are most fully realized when a premature death is avoided in a person who otherwise would be expected to live many more years. When individuals have limited longevity due to advanced age, or comorbid conditions at any age, the potential benefits of cancer screening are less clear, and the possibility of harms exceeding benefits become an important consideration. To date, referring clinicians have had some — but not detailed — guidance about when to stop cancer screening, or when a discussion about pros and cons of continuing screening is appropriate. Greater specificity has been urgently needed, if nothing else to prevent cessation of screening too early among patients who still will benefit from screening vs. continuing screening in patients who have life-limiting comorbid conditions and not only are unlikely to benefit, but could have their quality of life in the remaining years significantly diminished.
As noted by Lansdorp-Vogelaar and colleagues, these considerations should begin long before the age of 75 years, because a growing number of adults already have significant, life-limiting comorbidity. It also is important to consider patient choice for some cancer screening, which not only may be desired by the patient in good health, but may also be beneficial up to and even after age 80 years. As a greater fraction of the population reaches ages when the benefits of screening need to be considered in the context of longevity and tradeoffs, these data — and especially data specific to different screening tests — will become an important aid to help clinicians ensure their patients are able to make informed decisions.