Older Adults Get Cancer Screenings Against Recommendations

Dec. 12, 2011— -- Most adults 75 and older undergo cancer screenings, even though the U.S. Preventive Services Task Force recommends against routine screening for certain cancers in that age group, according to a study published in Archives of Internal Medicine.

Researchers led by Keith Bellizzi, an assistant professor of human development and family studies at the University of Connecticut in Storrs, found that among 1,697 adults between the ages of 75 to 79, 57 percent were screened for colorectal cancer, 62 percent were screened for breast cancer and 56 were screened for prostate cancer. Adults older than 80 were screened less often -- 38 percent of the 2,376 adults in this age group received screening for cervical cancer and 50 percent were screened for breast cancer.

"What we found, generally, was that a high percentage of older adults are continuing to undergo cancer screening, despite ambiguity regarding recommendations," said Bellizzi. "We even see those rates as relatively high in adults 80 years or older."

Other factors correlated with screening were physician recommendations, education level and certain medical conditions. Older adults were more likely to get screened if their doctors recommended it, if they were college educated and, regarding prostate cancer screening, if they had other medical conditions.

Bellizzi explained he and his colleagues wanted to get an idea of how many older Americans were still getting screened for cancer. The findings, he hopes, will lead to dialogue about what factors should be taken into account when making screening recommendations.

"The important question that is raised as a result of these findings is what are the factors physicians should consider in deciding to screen? he said. "And how do we decide whether to screen or not to screen?"

There have not been many studies evaluating how effective screening is in the older adult population. Most research has focused on younger adults, and recommendations are based on findings of these studies.

Age Just a Number When It Comes to Screening

Cancer experts say there are a number of variables to consider when recommending screening, and relying solely on a person's chronological age may not be the best way to determine whether screening is necessary. Life expectancy and current health status are also important.

"For breast cancer, colorectal cancer and cervical cancer -- the cancers for which screening has been proved to be effective -- if a person has less than five years to live, then screening is not beneficial," said Dr. Locovico Balducci, program leader of the Senior Adult Oncology Program at the Moffitt Cancer Center in Tampa, Fla. "But if it's longer and if a patient can tolerate cancer treatment, they shouldn't be denied screening."

But determining life expectancy can be tricky, and patients may also have very strong beliefs about the need for screening, so doctors will often still recommend screening tests.

"There's no crystal ball -- we don't know what life expectancy is for sure, and patients may be really concerned about cancer. Doctors and patients may still want screening to occur, and that's a tough thing to fight," said Dr. David Penson, professor of urologic surgery at Vanderbilt University Medical Center at Nashville.

The benefits of prostate cancer screening are less clear, and there has long been a debate over its effectiveness. Balducci says there's little proof that prostate cancer screening is effective, and Penson said there's little benefit if life expectancy is less than 10 years.

And the controversy of the benefits of screening isn't restricted to older adults. A recent study of more than 100,000 women 50 and older found that mammograms may actually be harmful because of the risk of false positives and the potential for unnecessary surgery.

Although there are guidelines in place, Bellizzi said determining who gets screened goes far beyond a raw age.

"This isn't a one-size-fits-all solution," he said.

In an accompanying editorial, Dr. Louise Walter, a geriatrician at the San Francisco VA Medical Center wrote that rather than debate about whether screening in older adults is right or wrong, the more important issue is whether patients are well informed about the benefits of screening and can make decisions based on that knowledge.

"While arguments persist about what is the 'right' rate of cancer screening in older persons, it seems clear that the rate of informed decision-making should approach 100 percent," Walter wrote.

MRIs in Certain Situation Not Effective, Says Another Study

Other research has also shown that despite recommendations, another type of testing may not offer any benefits.

Researchers led by Dr. Steven P. Cohen, an associate professor of anesthesiology and critical care medicine at the Johns Hopkins School of Medicine in Baltimore found that getting MRIs before receiving epidural steroid injections did not improve the pain in patients suffering from radiating leg pain and also had little effect on how physicians treated the problem. Compared to physicians who used MRI results to guide treatment decisions, physicians who did not use MRI results brought about similar pain relief.

Radiating leg pain is most commonly caused by either a herniated disc or spinal stenosis.

"This study is another in a long line of research that shows that 'more is not necessarily better' -- at least for pain," said Cohen. "Previous research showed that MRIs don't improve outcomes for most patients with back pain, or affect decision-making, which prompted the American College of Physicians to recommend them only for serious nerve involvement or when referring patients for either surgery or epidural steroid injections."

But other medical associations do recommend MRIs before giving steroid injections to people with this type of pain in order to rule out certain conditions that would make injections unsafe, such as tumors and fractures.

Dr. Scott Boden, director of the Emory Orthopedics & Spine Center in Atlanta, said a specialist can often determine whether epidural injections will be beneficial as well as where along the spine the steroids should go without an MRI scan.

"In most cases of people with leg pain, from a physical examination and a medical history, a specialist can make a diagnosis of whether it's a herniated disc or spinal stenosis, and can get a good idea of where to put a steroid injection," he said. Boden was not involved in the research.

In many cases, nonspecialists will order MRIs because they are not familiar with treating this type of pain, he said.

But there are some cases where an MRI can be helpful, such as if the pain does not respond to treatment after a certain amount of time or in some cases of herniated discs when it would be more helpful to specifically target the area for steroid injections.

However, in an accompanying editorial, Dr. Janna Friedly of the University of Washington and Dr. Richard Deyo of Oregon Health and Science University wrote that there are benefits of MRIs that support the recommendations.

"The use of MRI may have reduced the total number of injections required and may have improved outcomes in a subset of patients," they wrote. "Given these potential benefits as well as concerns related to missing important rare contraindications to epidural steroid injection, it seems premature to counsel against guideline recommendations for obtaining MRI prior to consideration of epidural steroid injections."