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Contrary to recommendations set by the U.S. Preventive Services Task Force, many Americans are getting screened for cancer even when old age or poor health would likely render such screenings risky and pointless, new research finds.
The task force notes that screening always entails some degree of risk, and cancer treatment can be harsh. So the reasoning is that neither the risk nor the ordeal are worth it for those who don't have long to live anyway.
But after reviewing the 2018 screening histories of over 176,000 patients, Penn State investigators determined that many patients were getting "overscreened."
At an average age of 75, roughly 55,000 men and women got tested for colorectal cancer, 83,000 women for cervical cancer and 38,000 women for breast cancer. Overscreening rates were pegged at 60% of men and 56% of women for colorectal cancer tests; 46% for cervical cancer; and 74% for breast cancer.
"For more invasive procedures, such as colonoscopy for colorectal cancer screening, side effects can be even more serious, such as complications from anesthesia and perforation of the bowels," noted Moss, who is an assistant professor of family and community medicine and public health sciences with Penn State College of Medicine.
Side effects go up with age, she added. Beyond that, "the tests don't have a proven benefit for improving life expectancy" for those above the task force's upper age limits, Moss explained.
The upshot: ignoring the task force's advice "translate[s] into many, many unnecessary tests, costs and potential harms," she noted.
Her team found that women (but not men) living in or near cities were more prone to get overscreened.
As to why, investigators theorized that women outside of urban centers may have more trusting relationships with doctors, that screening may also be less accessible in rural areas, and that urban dwellers might be getting more automated screening reminders.
More broadly, Moss said that patients may be unfamiliar with the task force's advice, while doctors may be uncomfortable touching on issues related to life expectancy. But she added that insurance companies pose a particular problem.
To reduce overscreening, "the strategy that would have the biggest impact would likely be if insurance companies stopped reimbursing providers for these screening tests that go against national guidelines," she said.
Still, Moss stressed that doctors can also help by talking to elderly patients "about 'graduating' from screening so they come to expect that cancer screening ends at some point."
Smith acknowledged that both patients and some doctors need to be better informed about the protocols, and that doctors need to step up and have hard conversations when warranted.
"But there's also a flip side," he added. "Yes, it may not make sense to send a patient to get a mammogram if they have really severe COPD and just one year life expectancy. But what does a physician do when an elderly person walks in in stunningly good health? Say a perfectly healthy 75-year-old. Her life expectancy is about 18 years. And at that point in her life, breast cancer incidence is very high, and patients may benefit from getting an early diagnosis," Smith explained.
"That may not necessarily be overscreening," he said.
Smith added that it's worth considering whether in some cases the task force guidelines are too conservative, "because the larger question is that we want to prevent premature deaths among healthy people as long as they can be avoided, and as long as the person has a significant number of years of life to benefit from that intervention."
The report by Moss and colleagues was published online recently in JAMA Network Open.
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