In this issue, Albert and Clark address the increasingly common challenge of how long to continue cancer screening in older patients.1 The most salient points in their article are highlighted in the tables. The statistics they report provide a more useful approach to cancer screening in the older patient compared with many of the current guidelines that are based on age alone.
First, patients and physicians should consider life expectancy. Table 11 in the article shows the life expectancies for men and women 65 years and older. Although it is sometimes considered taboo, it is critical to discuss life expectancy with patients who have diseases with natural histories, such as cervical, breast, colon, and prostate cancers. Unless there is evidence that the incidence of a certain cancer is lower in older patients, as with cervical cancer, screening guidelines should be based on each patient's life expectancy rather than age.2 Age alone should not be used as an important variable in clinical decision making. The primary role of age should be to help us determine life expectancy, not a patient's health status.
Second, we should consider each patient's comorbidities. Table 21 shows how life expectancy is determined in part by comorbidities. These numbers can help us to prioritize older patients' problems. When serious chronic illnesses or functional impairments are present, it may be time to find out what is important to the patient rather than reflexively performing more tests. Too often, the latter is easier, quicker, and even recommended, but it may not be the best thing for the patient. We should move away from the single disease model (i.e., trying to prevent a specific disease without considering other diseases the patient has).3 Also, when possible, decisions should be based on studies that include patients with several comorbidities and that track life expectancy and functional status. The data may help us predict whether the benefits of screening outweigh the risks.
Third, it is important to discuss patients' life-time risk of dying from particular cancers (Table 31), as well as quality of life. One of the best objective measures of older patients' health is function, which is intricately related to quality of life. Basic and Instrumental Activities of Daily Living are perhaps the corner-stones of health care for older patients.4 Not only is life expectancy predicted by functional level,5,6 but a loss of function is associated with institutionalization,7 something feared by many older persons. A patient may be less likely to opt for cancer screening if loss of function is likely to precede any symptomatic cancer.
Finally, if cancer screening in older patients is going to be based on patient preferences in addition to available evidence, then it is time to emphasize health literacy.8 In Healthy People 2010, health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”9 One way to encourage health literacy is to have a careful discussion about cancer screening with each patient. This is a lofty goal and one that frustrates many physicians. We would love to do this with every patient; and when we can, it is quite rewarding. However, it may not be practical for most busy primary care physicians.
Health literacy enables patients to understand the information we give them, as well as seek out information for themselves and use it to make informed decisions. Someday our patients will arrive at our office already knowing statistics such as those outlined in Table 3.1 Some are already aware of these numbers. It will be rewarding when patients are ready to discuss cancer screening based on what is most important to them, rather than on guidelines set by medical societies trying to make one size fit all.