I’m older, so should I still get cancer screenings?

The U.S. Preventive Services Task Force sets age guidelines for both the lower and upper ages that patients should be screened for various cancers. Deciding whether to continue cancer screening as we age can be a difficult decision, but the trend now is to factor life expectancy into the decision of what screening a patient should receive.

“At the Senior Oncology Clinic that we have (at Cape Cod Hospital) we try to treat patients based on their physiological age, not on their chronological age,” said hematologist/medical oncologist Peter Ward, MD, who practices at the Davenport-Mugar Cancer Center at Cape Cod Hospital. “That goes into the decision for treatment as well.”

Deciding to stop screening can be a controversial topic that many doctors and patients would rather avoid, he said. It may be hard for some people to hear that their doctor thinks they have less than 10 years left.

Doctors regularly use risk calculators like ePrognosis to figure out an estimated life expectancy. They plug in details like the patient’s age, BMI and medical history and the calculator can estimate the patient’s risk of dying at five years, 10 years and 14 years. Patients can access the same information, but Dr. Ward recommends they do so with the help of their doctor.

Talking to a patient about the state of their health as it relates to their ability to tolerate cancer treatment can be hard for some healthcare providers, especially if they have a longstanding relationship with the patient, Dr. Ward said. For one thing, patients tend to be optimistic about their actual health. Everyone wants to believe they are healthier than they are, he said.

Be Open to the Facts

Dr. Ward encourages people to be open to discussing it with their doctor before deciding whether to go forward with screening or treatment, or not. Doctors can assess things like your family history, personal risk factors and level of frailty. They can also discuss the benefits and dangers of screening, because not all screening is benign.

“On average most patients think invasive procedures are simpler than they actually are and I don’t think they fully understand the risks,” Dr. Ward said. “Even with colonoscopy, the risk of having a bowel perforation is somewhere between 0.1 and 0.5 percent and that gets higher as you get older. The risk of anesthesia also gets higher when you get older, in terms of cardiac stress and all of those things. But I don’t think the average person really knows that.”

The other factor for screening is how quickly the type of cancer is likely to grow. For example, the recommendation for colonoscopy is every 10 years, he said. That means that it is presumed that it would take that long for a polyp to turn cancerous.

Prostate cancer also tends to be slow-growing. Prostate cancers are graded with something called the Gleason Scale and most are low-grade cancers. The Gleason score starts at 6 and goes to 10. Anything below a six is considered precancerous.

“But a Gleason six prostate cancer, which is the most diagnosed grade of prostate cancer, sometimes never actually affects a patient physically,” Dr. Ward said. “It is a disease that can be monitored without any treatment sometimes for many years. So that’s the type of cancer where over screening probably happens the most often.”

Since prostate cancer screening is a simple PSA blood test, it’s easy for doctors to order it, but then they are left with the results and they have to consider what the next steps are, if the test is positive. A patient in poor health might not be able to easily tolerate a prostate biopsy so why do a PSA?

The Patient’s Decision

“The bottom line is it’s a complicated decision,” Dr. Ward said. “But people should keep in mind that the U.S. Preventive Services Task Force recommendation for age ranges are meant to be guidelines to counsel patients about when to continue screening and when to stop screening. In the end, it depends on a patient’s longevity and whether or not they would be fit to go through any treatment if a cancer was diagnosed on a screening test.”

That said, most patients want to continue screening until they are really debilitated and that is their personal choice to make.

“Most physicians are advocates for patient autonomy,” he said. “We don’t really try to practice paternalistic medicine. It’s shared decision making with patients. I think it’s the physician’s job to make the patient aware of the risk and benefits of screening tests, but ultimately it is the patient’s decision in the end.”