Choosing Wisely:

Don’t recommend screening for breast, colorectal or prostate cancer if life expectancy is estimated to be less than 10 years.

Rationale and Comments: Many patients residing in the long-term care setting are elderly and frail, with multimorbidity and limited life expectancy. Although research evaluating the impact of screening for breast, colorectal, and prostate cancer in older adults in general and long-term care residents in particular is scant, available studies suggest that multimorbidity and advancing age significantly alter the risk-benefit ratio. Preventive cancer screenings have both immediate and longer term risks (e.g., procedural and psychological risks, false positives, identification of cancer that may be clinically insignificant, treatment-related morbidity and mortality). Benefits of cancer screening occur only after a lag time of 10 years (colorectal or breast cancer) or more (prostate cancer). Patients with a life expectancy shorter than this lag time are less likely to benefit from screening. Discussing the lag time (“When will it help?”) with patients is at least as important as discussing the magnitude of any benefit (“How much will it help?”). Prostate cancer screening by PSA testing is not recommended for asymptomatic patients because of a lack of life-expectancy benefit. One-time screening for colorectal cancer in older adults who have never been screened may be cost-effective; however, it should not be considered after age 85 and for most long-term care patients older than 75 the burdens of screening likely outweigh any benefits.
Sponsoring Organizations:
  • Society for Post-Acute and Long-Term Care Medicine
  • Sources:
  • Expert consensus
  • Disciplines:
  • Geriatric Medicine
  • Preventive Medicine
  • Oncologic
  • References: • Clarfield AM. Screening in frail older people: an ounce of prevention or a pound of trouble? J Am Geriatr Soc. 2010 Oct;58:2016-21.
    • Gill TM. The central role of prognosis in clinical decision making. JAMA. 2012 Jan 11;307(2):199-200.
    • Gross CP. Cancer screening in older persons: a new age of wonder. JAMA Intern Med. 2014 Oct;174(10):1565-7.
    • Lee SJ, Leipzig RM, Walter LC. Incorporating lag time to benefit into prevention decision for older adults. JAMA. 2013 Dec (25);310(24):2609-10.
    • Lonsdorp-Vogelaar I, Gulati R, Mariotto AB, Schechter CB, de Carvalho TM, Knudsen AB, van Ravesteyn NT, Heijnsdijk EA, Pabiniak C, van Ballegooijen M, Rutter CM, Kuntz KM, Feuer EJ, Etzioni R, de Koning HJ, Zauber AG, Mandelblatt JS. Personalizing age of cancer screening cessation based on comorbid conditions: model estimates of harms and benefits. Ann Intern Med. 2014 Jul 15;161(2):104-12.
    • Moyer VA. Screening for prostate cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2012 Jul 17;157(2):120-34.
    • Royce TJ, Hendrix LH, Stokes WA, Allen IM, Chen RC. Cancer screening rates in individuals with different life expectancies. JAMA Intern Med. 2014 Oct;174(10):1558-65.
    • Spivack B, Cefalu C, Kamel H, et al. Health Maintenance in the Long Term Care Setting Clinical Practice Guideline. 2012. Columbia, MD: American Medical Directors Association.
    • van Hees F, Habbema JD, Meester RG, Lansdorp-Vogelaar I, van Ballegooijen M, Zauber AG. Should colorectal cancer screening be considered in elderly persons without previous screening? A cost-effectiveness analysis. Ann Intern Med. 2014 Jun 3;160(11):750-9.
    • Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 2001 Jun 6;285(21):2750-6.

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