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Cancer screening decisions for the elderly should not be based on age alone

Considerable uncertainty exists about optimal cancer screening in elderly patients. Doctors should estimate the expected benefit of screening for a specific individual and not rely solely on age-specific guidelines. Also, since the outcomes of screening decisions affect elderly patients directly, doctors should allow them to share in these decisions, recommend Louise C. Walter, M.D., and Kenneth E. Covinsky, M.D., M.P.H., of the University of California, San Francisco. Their research was supported in part by the Agency for Healthcare Research and Quality (K02 HS00006).

Drs. Walter and Covinsky developed a framework to guide elderly patients and their doctors in individualized screening decisions. Their framework anchors decisions with quantitative estimates of life expectancy, risk of cancer death, and screening outcomes based on published data. They present potential benefits of screening as the number of people who must be screened to prevent one cancer-specific death based on the estimated life expectancy during which a patient will be screened. For example, those with life expectancies of less than 5 years are unlikely to derive any survival benefit from cancer screening.

The researchers also consider the likelihood of potential harm from screening based on patient factors and test characteristics. These harms include complications from additional diagnostic procedures due to inaccurate test results, identification and treatment of clinically unimportant cancers (cancers that would never have become clinically significant), and the psychological distress that can result from screening (the alarm of false-positive results and the anxiety caused by a "temporary" diagnosis of cancer).

Considering the estimated outcomes according to the patient's own values and preferences is the final step. The value placed on different health outcomes will vary among patients, as will preferences for screening. For example, some patients may want to avoid the worry and risk of a cascade of further tests that may follow an ambiguous result of a screening test.

In conclusion, the researchers note that cancer screening discussions and decisions are difficult tasks, and that optimizing cancer screening decisions will require medical systems that reimburse doctors for the complexity and time requirements associated with these discussions.

See "Cancer screening in elderly patients: A framework for individualized decision making," by Drs. Walter and Covinsky, in the June 6, 2001 Journal of the American Medical Association 285(21), pp. 2750-2756.

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