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These Medical Tests May Do More Harm Than Good In Older Patients

For many, frequent trips to the doctor are just part of old age.  

And while many elderly men and women consider going to the doctor just part of their routine, many geriatricians, cancer specialists and health system analysts say they are being subject to what they consider “unnecessary testing."

They say that testing our nation’s oldest members is highly unlikely to uncover lethal disease, is extremely expensive and could prove to be harmful due to the potential invasive nature of follow-up testing and treatment. 

However, even with these warnings and without the support of many geriatric health experts this type of “overdiagnosis” testing is running rampant in the United States. 

Primarily due to the existing medical culture, awareness campaigns funded by Big Pharma and diagnostic testing companies and the financial incentive programs aimed at doctors. 

“By looking for cancers in people who are unlikely to benefit, "we find something that wasn't going to hurt the patient, and then we hurt the patient," said Dr. Sei Lee, an associate professor of geriatrics at the University of California-San Francisco.

In fact, nearly 1 in 5 women suffering with cognitive impairment, including the most elderly are still getting regular mammograms according to American Journal of Public Health.1

In spite of the fact that they have a shorter life expectancy to begin with. 

And according to a 2014 study published in JAMA Internal Medicine 2, 55 percent of elderly men at high risk for death over the next 10 years are still getting PSA tests for prostate cancer. 

Once people reach their 70’s and 80’s cancer screenings often detect slow growing tumors and these types of tumors are unlikely to cause problems during the patient’s lifetime anyway. 

According to Dr. Deborah Korenstein, chief of general internal medicine at New York's Memorial Sloan Kettering Cancer Center…

Normally, these patients die of other causes, including things like heart disease, dementia and pneumonia. And they usually die long before their cancer would have ever become life-threatening."

She went on to say that, “Prostate cancers, in particular, are often harmless”.

Statistics show that patients with dementia rarely live longer than a few years anyway and unnecessary testing simply adds to their confusion.3

The problem with cancer screenings is that both patients and doctors alike, are highly enthusiastic about them. 

However, both tend to overestimate their benefits. 

And they often underestimate their risk.

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

This excessive testing has even gotten to the point where some women are being screened for tumors in organs they don’t even have. 

One study published in JAMA Internal Medicine found that nearly two-thirds of women over the age of 30 who had undergone a hysterectomy received at least one cervical cancer screening. And a full one-third of those women had been screened in the past year.4

Screening Terminal Cancer Patients…Why?

The testing trend has gotten so out of hand that even patients who’ve been diagnosed with terminal cancers are still being screened for additional malignancies.

In one 2010 study, nine percent of women with advanced cancers – including tumors of the lung, colon or pancreas – also received a mammogram and 6 percent received a cervical cancer screen.5

In addition, 15 percent of the men on Medicare with incurable cancer were screened for prostate cancer.

And while screenings can extend life and improve the quality of life for healthy, younger adults, they have a tendency to cause harm to the elderly.

Including anxiety, invasive follow-ups and particularly harsh treatments. 

Dr. Cary Gross, a professor at the Tale School of Medicine says, 

"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."

When doctors screen patients near the end of their life, they often find tumors that don’t need to be found let alone treated. 

In fact, experts estimate that nearly two-thirds of prostate cancers and up to one-third of breast cancers are over diagnosed.6, 7

And according to experts, overdiagnosis is a serious problem. 

So much so that organizations like the American College of Surgeons and The Society of General Internal Medicine have advised doctors against screening patients with little time left. 

Even the American Cancer Society only recommends testing patients for prostate and breast cancer who are expected to live at least another ten years or more.

Over testing has gotten so out of hand, that doctors have even formed coalitions along with patient advocates and employers to stop the excessive testing. And one such coalition co-directed by Dr. A Mark Fendrick has included prostate screenings for men over 75 in its list of the top 5 “low-value” medical procedures. 8

They cite a study in the journal Cancer 9 that showed that prostate screenings on men over 75 cost Medicare as much as $145 million each year. 

And mammograms performed in this age group cost federal health plans more than $410 million each year according to a 2013 study in JAMA Internal Medicine.10

And while the argument is that these cancer screenings aren’t expensive, for example a mammogram costs around $100…the results tend to result in a variety of additional treatments that add to the overall cost. 

Plus, according to a study published in Health Affairs, most of the spending on unneeded medical care is not because of high cost procedures like heart surgeries, but cheaper less expensive medical procedures performed way too often.11

But Patient’s Want The Screenings

According to Dr. Mara Schonberg, an associate professor at Harvard Medical School and Boston's Beth Israel Deaconess Medical Center “One of the biggest problems is that elderly patients are still wanting and expecting these screenings. 

"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 said.

And with many seniors living well into their 90’s, many feel that the screenings are necessary and should be part of their regular medical checkups.

This is partly due to the popularity of public awareness campaigns.  

Public Awareness campaigns are notorious for changing people’s beliefs around certain diseases. And because of this, many seniors have come to believe that regular cancer screenings are essential to their health and longevity. 

But one thing these campaigns fail to mention is that a doctor has to screen 1,000 women for at least a decade just to prevent one death.12

The Deadly Side Of Screenings

Not all screenings are harmless and medical complications can and often do arise. 

For example, intestinal tears from a colonoscopy occur almost twice as frequently in patients ages 75-79 compared to those 70-74.13

Not to mention, colonoscopies which require extensive bowel cleansing prior to the procedure can leave the elderly dehydrated and prone to fainting spells. 

And PSA testing can lead to more invasive needle biopsies. This procedure can cause infection in about six percent of men. 

Once an infection sets in approximately 1 in 100 men end up in the hospital.14

Even something as benign as the removal of a nonfatal skin cancer can be problematic for the elderly according to Dr. Eleni Linos, an associate professor at the University of California-San Francisco School of Medicine. 

Patients who are elderly and frail can have difficulties caring for wounds or changing bandages. Their wounds are also less likely to heal quickly. 

In fact, according to Dr. Lino’s own research, more than 1 in 4 patients with nonfatal skin cancers report a complication of treatment.

Even with high complication rates, most of the 2.5 million slowest-growing skin cancers are still discovered in people over 65.15

The Emotional Costs

But physical trauma is not the only kind of trauma the elderly are at risk for. These screenings, follow-up tests and treatments also cause their share of emotional trauma. 

The confusion and anxiety associated with exposing themselves and having to press their body parts against machines can be very traumatizing and upsetting. 

In fact, about 70 percent of older women report significant levels of stress during a biopsy and the act of laying still on a table for 45-min can cause pain for those with severe arthritis. 

And according to experts, most older women with breast cancer end up getting surgery, which can cause additional emotional and physical stress. Often the women are prescribed hormonal therapies that can weaken their bones, cause fatigue and increase their risk of stroke.

Alternatives

In the treatment of prostate cancer, some doctors are doing their best to limit unnecessary treatment by offering men with “early-stage disease” what they call active surveillance instead of invasive treatments.

In a study published in the New England Journal of Medicine researchers found that men were just as likely to survive 10 years whether they chose to be treated or simply monitored.16

And for those who choose the surgical route 14 percent lose bladder control and 14 percent develop erectile dysfunction according to a study published in JAMA Internal Medicine.17

Hard Habit To Break

When it comes to ordering tests, doctors have a number of good reasons to continue testing their elderly patients. 

For one, doctors are busy and it’s a lot easier for them to simply allow their aging patient population to continue getting the tests they’ve grown accustomed to. Instead of trying to convince them there is simply no point because they are nearing the end of their life. 

Plus, doing less is often perceived as the doctor not caring and many physicians would rather be liked and appreciated than save the government money.

That’s why doctors need to get their priorities straight when it comes to helping elderly patients live longer and healthier lives. 

Dr. Louise Walter, chief of geriatrics at the University of California-San Francisco and a geriatrician at the San Francisco VA Medical Center suggests, 

"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?" 

There are also a variety of other issues to focus on like fall prevention, depression and overall quality of life. 

These things are much more important than screening for diseases that aren’t likely to cause problems and by focusing on these issues instead patients won’t be put at risk unnecessarily.

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References:

1. Mehta, Kala M. et al. "Impact Of Cognitive Impairment On Screening Mammography Use In Older U.S. Women." Alzheimer's & Dementia 5.4 (2009): P237.

2. Royce, Trevor J. et al. "Cancer Screening Rates In Individuals With Different Life Expectancies." JAMA Internal Medicine 174.10 (2014): 1558.

3. Mehta, Kala M. et al. "Impact Of Cognitive Impairment On Screening Mammography Use In Older U.S. Women." Alzheimer's & Dementia 5.4 (2009): P237.

4. Kepka, Deanna et al. "Overuse Of Papanicolaou Testing Among Older Women And Among Women Without A Cervix." JAMA Internal Medicine 174.2 (2014): 293.

5. Sima, Camelia S., Katherine S. Panageas, and Deborah Schrag. "Cancer Screening Among Patients With Advanced Cancer." JAMA 304.14 (2010): 1584.

6. Loeb, Stacy et al. "Overdiagnosis And Overtreatment Of Prostate Cancer." European Urology 65.6 (2014): 1046-1055.

7. Liz Szabo, Kaiser Health News. "Third Of Breast Cancer Patients Treated Unnecessarily, Study Says." CNN.

8. Buxbaum, Jason, John Mafi, and Mark Fendrick. "Tackling Low-Value Care: A New “Top Five” For Purchaser Action." HEALTH AFFAIRS BLOG.

9. Ma, Xiaomei et al. "The Cost Implications Of Prostate Cancer Screening In The Medicare Population." Cancer 120.1 (2013): 96-102.

10. Gross, Cary P. et al. "The Cost Of Breast Cancer Screening In The Medicare Population." JAMA Internal Medicine 173.3 (2013): 220.

11. Mafi, John N. et al. "Low-Cost, High-Volume Health Services Contribute The Most To Unnecessary Health Spending." Health Affairs 36.10 (2017): 1701-1704.

12. "How Tiny Are Benefits From Many Tests And Pills? Researchers Paint A Picture." Kaiser Health News.

13. García-Albéniz, Xabier et al. "Effectiveness Of Screening Colonoscopy To Prevent Colorectal Cancer Among Medicare Beneficiaries Aged 70 To 79 Years." Annals of Internal Medicine 166.1 (2016): 18.

14. Lundström, Karl-Johan et al. "Nationwide Population Based Study Of Infections After Transrectal Ultrasound Guided Prostate Biopsy." The Journal of Urology 192.4 (2014): 1116-1122.

15. Linos, Eleni, Steven A. Schroeder, and Mary-Margaret Chren. "Potential Overdiagnosis Of Basal Cell Carcinoma In Older Patients With Limited Life Expectancy." JAMA 312.10 (2014): 997.

16. Hamdy, Freddie C. et al. "10-Year Outcomes After Monitoring, Surgery, Or Radiotherapy For Localized Prostate Cancer." New England Journal of Medicine 375.15 (2016): 1415-1424.

17. Walter, Louise C. et al. "Five-Year Downstream Outcomes Following Prostate-Specific Antigen Screening In Older Men." JAMA Internal Medicine 173.10 (2013): 866.

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