Oct. 13, 2010
Many senior citizens with advanced cancer and a short life expectancy
are still undergoing common cancer screening that is unlikely to provide
meaningful benefit, according to a study of thousands of Medicare
patients. A possible policy implication, the researchers suggest, would
be for Medicare to deny coverage for cancer screening of patients with
life expectancy of less than 2 years.
Cancer screening
programs, such as mammography, Papanicolaou test, prostate-specific
antigen (PSA) and colonoscopy, evaluate asymptomatic patients for the
detection of early forms of cancer and have contributed substantially to
the decline in deaths from cancer, note the authors of the report in
todays Journal of the American Medical Association (JAMA).
"Although the
benefits of cancer screening are compelling for most members of the
population, its value is less certain for patients with concurrent
illnesses that severely limit life expectancy, they say.
In the extreme
situation of patients with advanced cancer, screening will lead to over
diagnosis (detection of a cancer which, if not found by active search,
would not affect survival) in virtually all cases when a new malignancy
is found.
In addition,
patients may be subject to unnecessary risk due to subsequent testing,
biopsies, and psychological distress," the authors write. Current
cancer screening guidelines do not directly address the appropriateness
of screening for individuals with terminal illness, according to
background information in the article.
Camelia S. Sima,
M.D., M.S., of Memorial Sloan-Kettering Cancer Center, New York, and
colleagues examined the extent to which patients with advanced cancer
continue to undergo screening for new cancers and identified
characteristics associated with screening.
The study
included data on 87,736 fee-for-service Medicare enrollees ages 65 years
or older diagnosed with advanced lung, colorectal, pancreatic,
gastroesophageal, or breast cancer between 1998 and 2005, and reported
to one of the Surveillance, Epidemiology, and End Results (SEER) tumor
registries. Participants were followed up until death or December 2007,
whichever came first.
A group of
87,307 Medicare enrollees without cancer were individually matched by
age, sex, race, and SEER registry to patients with cancer and observed
over the same period to evaluate screening rates in context.
For both groups,
utilization of cancer screening procedures (mammography, Papanicolaou
test, PSA, and lower gastrointestinal [GI] endoscopy) was assessed. For
each cancer screening test, utilization rates were defined as the
percentage of patients who were screened following the diagnosis of an
incurable cancer.
The researchers
found that among women, following advanced cancer diagnosis
compared with controls, at least 1 screening mammogram was received by
8.9 percent vs. 22.0 percent and Papanicolaou test screening was
received by 5.8 percent vs. 12.5 percent.
Among men
with advanced cancer, 15.0 percent received PSA testing compared with
27.2 percent of controls.
For all
patients following advanced diagnosis compared with controls, lower
GI endoscopy was received by 1.7 percent vs. 4.7 percent.
Screening was
more frequent among patients with a recent history of screening. Higher
socioeconomic status and married status were significantly associated
with a higher probability of screening for each test evaluated.
"The strongest
predictor of screening in the setting of advanced cancer was the receipt
of a screening test before diagnosis. The most plausible interpretation
of our data is that efforts to foster adherence to screening have led to
deeply ingrained habits," the authors write.
Patients and
their health care practitioners accustomed to obtaining screening tests
at regular intervals continue to do so even when the benefits have been
rendered futile in the face of competing risk from advanced cancer."
"Our results
have several policy implications.
First, greater
awareness that screening in the face of limited life expectancy from
advanced cancer is of dubious benefit may in and of itself limit use.
Second, as
electronic medical records and reminder systems are developed to foster
screening adherence, they should also include program features that flag
when conditions suggest re-evaluation or cessation of screening based on
competing comorbidities. Electronic medical records increasingly have
the sophistication to track cancer stage at diagnosis and disease status
and to link this to screening reminder systems.
Alternatively,
the Medicare program might not provide coverage for cancer screening
procedures for patients with life expectancy of less than 2 years."
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