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Doing More Harm Than Good? Epidemic of Screening Burdens Nation’s Older Patients

Elena Altemus is 89 and has dementia. She typically forgets her youngsters’s names, and generally can’t recall whether or not she lives in Maryland or Italy.

Yet Elena, who entered a nursing dwelling in November, was screened for breast most cancers as just lately as this summer season. “If the screening is not too invasive, why not?” requested her daughter, Dorothy Altemus. “I want her to have the best quality of life possible.”

But a rising refrain of geriatricians, most cancers specialists and well being system analysts are coming forth with a bunch of causes: Such testing within the nation’s oldest sufferers is extremely unlikely to detect deadly illness, massively costly and extra more likely to hurt than assist since any follow-up testing and remedy is commonly invasive.

About This Series

In this collection, “Treatment Overkill,” Kaiser Health News investigates the causes and penalties of medical overtreatment, each for sufferers and the well being care system.

And but such screening — some have labeled it “overdiagnosis” — is epidemic within the United States, the results of medical tradition, aggressive consciousness campaigns and monetary incentives to medical doctors.

By in search of cancers in people who find themselves unlikely to profit, “we find something that wasn’t going to hurt the patient, and then we hurt the patient,” stated Dr. Sei Lee, an affiliate professor of geriatrics on the University of California-San Francisco.

Nearly 1 in 5 ladies with extreme cognitive impairment — together with older sufferers like Elena Altemus — are nonetheless getting common mammograms, in accordance with the American Journal of Public Health — regardless that they’re not really helpful for individuals with a restricted life expectancy. And 55 % of older males with a excessive danger of dying over the following decade nonetheless get PSA assessments for prostate most cancers, in accordance with a 2014 study in JAMA Internal Medicine.

Among individuals of their 70s and 80s, most cancers screenings typically detect slow-growing tumors which can be unlikely to trigger issues in sufferers’ lifetimes. These sufferers typically die of one thing else — from dementia to coronary heart illness or pneumonia — lengthy earlier than their cancers would ever have turn into a risk, stated Dr. Deborah Korenstein, chief of basic inner medication at New York’s Memorial Sloan Kettering Cancer Center. Prostate cancers, particularly, are sometimes innocent.

Patients with dementia, for instance, rarely live longer than a few years.

“It generally takes about 10 years to see benefit from cancer screening, at least in terms of a mortality benefit,” Korenstein stated.

Enthusiasm for most cancers screenings runs excessive amongst patients and doctors, each of whom are inclined to overestimate the advantages however underappreciate the dangers, medical analysis exhibits.

In some circumstances, ladies are being screened for tumors in organs they now not have. In a examine of girls over 30, practically two-thirds who had undergone a hysterectomy received no less than one cervical most cancers screening, together with one-third who had been screened prior to now 12 months, in accordance with a 2014 study in JAMA Internal Medicine.

Even some sufferers with terminal cancers proceed to be screened for different malignancies.

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Nine % of girls with superior cancers — together with tumors of the lung, colon or pancreas — acquired a mammogram and 6 % acquired a cervical most cancers display, in accordance with a 2010 study of Medicare recipients over age 65. Among males on Medicare with incurable most cancers, 15 % have been screened for prostate most cancers.

Although screenings can lengthen and enhance lives for wholesome, youthful adults, they have a tendency to inflict extra hurt than good in people who find themselves outdated and frail, Korenstein stated. Testing can result in nervousness, invasive follow-up procedures and harsh remedies.

“In patients well into their 80s, with other chronic conditions, it’s highly unlikely that they will receive any benefit from screening, and more likely that the harms will outweigh the benefits,” stated Dr. Cary Gross, a professor on the Yale School of Medicine.

By screening sufferers close to the tip of life, medical doctors typically detect tumors that don’t should be discovered and handled. Researchers estimate that as much as two-thirds of prostate cancers are overdiagnosed, together with one-third of breast tumors.

“Overdiagnosis is serious,” Gross stated. “It’s a tremendous harm that screening has imposed. … It’s something we’re only beginning to reckon with.”

Quite a lot of medical specialties — from the American College of Surgeons to the Society of General Internal Medicine — have suggested medical doctors towards screening sufferers with restricted time left. For instance, the American Cancer Society recommends prostate and breast most cancers screenings solely in sufferers anticipated to dwell 10 years or extra.

In November, a coalition of affected person advocates, employers and others included prostate screenings in males over age 75 in its list of the top five “low-value” medical procedures. Dr. A. Mark Fendrick, co-director of the coalition, referred to the 5 procedures as “no-brainers,” arguing that well being plans ought to think about refusing to pay for them.

Prostate most cancers screening in males over 75 price Medicare no less than $145 million a 12 months, in accordance to a 2014 study in the journal Cancer. Mammograms on this age group price the federal well being plan for seniors greater than $410 million a year, in accordance with a 2013 examine in JAMA Internal Medicine.

Taxpayers normally foot the invoice for these assessments, as a result of most seniors are lined by Medicare.

And whereas most cancers screenings usually aren’t costly — a mammogram averages about $100 — they’ll launch a cascade of follow-up assessments and coverings that add to the whole price of care.

Most spending on pointless medical care stems not from uncommon, big-ticket gadgets, corresponding to coronary heart surgical procedures, however cheaper companies which can be carried out a lot too typically, in accordance with an October study in Health Affairs.

A Hard Habit To Break

Many older sufferers count on to proceed getting screened, stated Dr. Mara Schonberg, an affiliate professor at Harvard Medical School and Boston’s Beth Israel Deaconess Medical Center.

“It’s jarring for someone who’s been told every year to get screened and then at age 75 you tell them to stop,” she stated.

John Randall, 78, says he plans to dwell into his 90s. He sees no purpose to skip most cancers screening.

“I, for one, do not like to hear what my life expectancy is,” stated Randall, who lives close to Madison, Wis. He plans to have his subsequent colonoscopy in January. He feels wholesome and walks 2 miles at a stretch a number of days every week. “No one knows when I am going to die.”

Decades of public consciousness campaigns have satisfied sufferers that most cancers screenings are important, stated Dr. Lisa Schwartz, a professor on the Dartmouth Institute for Health Policy and Clinical Practice. Her research discovered that many individuals see most cancers screening as an ethical obligation and might’t think about a day once they would cease getting screened.

Such campaigns have satisfied many ladies that “mammograms saves lives.”

But these campaigns don’t point out that medical doctors have to display 1,000 ladies for a decade so as to prevent one death from breast most cancers, stated Schonberg.

Yet screenings can have dire penalties. Medical problems throughout colonoscopies — corresponding to intestinal tears — are nearly twice as frequent in sufferers ages 75 to 79 in contrast with these 70 to 74, in accordance with a study published in January in Annals of Internal Medicine.

Colonoscopies, which require intensive bowel cleaning earlier than the process, can also go away many older individuals dehydrated and susceptible to fainting.

PSA assessments can result in prostate biopsies — through which medical doctors use needles to pattern tissue — that trigger infections in about 6 % of males. These infections ship about 1 in 100 males who endure the process to the hospital, in accordance with a 2014 examine within the Journal of Urology.

Even eradicating nonfatal pores and skin cancers could cause issues for older sufferers, stated Dr. Eleni Linos, an affiliate professor on the University of California-San Francisco School of Medicine. Frail sufferers can wrestle to take care of surgical wounds and alter dressings; their wounds are additionally much less more likely to heal effectively, Linos stated. More than 1 in four sufferers with nonfatal pores and skin cancers report a complication of remedy, Linos’ analysis exhibits.

Yet many of the 2.5 million slowest-growing pores and skin cancers discovered annually are recognized in individuals over 65, in accordance with Linos’ 2014 study. More than 100,000 of those nonfatal pores and skin cancers are handled in sufferers who die inside one 12 months.

Screenings, follow-up assessments and coverings could cause emotional trauma as effectively.

“For a woman of that generation who doesn’t have the cognitive ability to understand what’s going on, having private parts of their body exposed and pressed against a machine can be very agitating and upsetting,” Lee stated.

Among older ladies, about 70 % report important stress on the time of a biopsy, Schonberg stated. Simply mendacity on a desk for a 45-minute biopsy could cause ache for ladies with important arthritis, she stated.

Instead of spending effort and time on issues which can be hurtful and by no means going to assist them, why not direct time and power on issues that can assist them dwell longer and higher?

Dr. Louise Walter

Virtually all older ladies with breast most cancers wind up getting surgical procedure, which poses extra hardships, Schonberg stated. Many are prescribed hormonal therapies that may trigger bone ache, fatigue and improve the chance of stroke.

With prostate most cancers, medical doctors as we speak attempt to scale back the hurt from overdiagnosis by providing males with early-stage illness “active surveillance” as an alternative of instant remedy. A examine revealed final 12 months within the New England Journal of Medicine discovered that males are simply as more likely to survive 10 years whether or not they select to be handled or monitored.

Jay Schleifer, 74, of Wellington, Fla., was recognized with a low-risk prostate most cancers final 12 months. Since then, his physician has monitored him with extra assessments. He’ll be handled provided that assessments recommend his most cancers has turn into extra aggressive.

This much less aggressive method goals to spare Schleifer from long-term negative effects.

Among males who’ve had prostate most cancers surgical procedure, 14 % lose management of their bladders and 14 % develop erectile dysfunction, in accordance with a 2013 study in JAMA Internal Medicine.

In a examine revealed in July within the Journal of Clinical Oncology, Dr. Richard Hoffman discovered 15 % of prostate most cancers survivors regretted their remedy resolution. Those handled with surgical procedure and radiation have been about twice as more likely to remorse their alternative in contrast with those that opted to watch their illness.

Men usually tend to remorse their prostate most cancers remedy choices in the event that they don’t perceive the dangers beforehand, stated Hoffman, director of basic inner medication on the University of Iowa Carver College of Medicine/Iowa City VA Medical Center.

Harold Honeyfield, 87, stated he didn’t absolutely perceive the dangers when he had prostate most cancers surgical procedure 12 years in the past. Although he’s glad he was handled, the surgical procedure induced irreversible erectile dysfunction, which has induced stress and unhappiness for him and his spouse of 47 years.

“When a man has no erections, that is paralysis,” stated Honeyfield, of Davis, Calif., who began a help group for different males coping with prostate most cancers. “You’ve lost the ability to be a man.”

A Tough Sell

Doctors have a variety of incentives to proceed ordering screening assessments as individuals age.

“It’s a lot easier to say, ‘Fine, get your regular mammogram this year,’ than to have the much more difficult conversation that it’s not helpful when life expectancy is limited,” Gross stated.

Schonberg stated she tries to be diplomatic when speaking to sufferers about halting screening.

In sufferers effectively into their 80s, with different power situations, it’s extremely unlikely that they are going to obtain any profit from screening.

Dr. Cary Gross

“It’s hard to tell people, ‘You’re not going to live long enough to benefit,’” Schonberg stated. “That doesn’t go over well.”

Many physicians proceed screening older individuals as a result of they’re afraid they’ll be sued in the event that they miss a most cancers, Schonberg stated. And she notes that some well being methods award bonuses to clinicians whose sufferers have excessive screening charges.

In addition, “doing less can be perceived as a lack of caring or as ageism,” Schonberg stated. “It can be uncomfortable for a physician to explain why doing less is more.”

Doctors ought to prioritize what they’ll do to assist sufferers be more healthy, stated Dr. Louise Walter, chief of geriatrics on the University of California-San Francisco and a geriatrician on the San Francisco VA Medical Center. For many older sufferers, screening for most cancers shouldn’t be their most urgent want.

“Instead of spending time and effort on things that are hurtful and never going to help them, why not direct time and energy on things that will help them live longer and better?” Walter requested.

For instance, Walter may inform a affected person, “‘Right now, you have really bad heart failure and we need to get that under control,’” Walter stated.

Other key points for a lot of older individuals embrace stopping falls, treating despair and assuaging stress of their caregivers, Walter stated. Gross stated he urges sufferers to take steps proven to enhance their well being, corresponding to getting a flu shot or exercising no less than 15 minutes a day.

“These are things that can help them feel better very quickly,” Walter stated. “Screenings can take years to have a benefit, if at all.”

KHN’s protection associated to getting old and enhancing care of older adults is supported partially by The John A. Hartford Foundation.

Liz Szabo: lszabo@kff.org”>lszabo@kff.org, @LizSzabo

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