A “meaningful proportion” of patients aged 65 years and older who have advanced cancer and a limited life expectancy undergo unnecessary screening for other cancers, needlessly exposing them to physical risk and psychological distress, according to a report in the Oct. 13 issue of JAMA.
Dr. Camelia S. Sima of the department of epidemiology and biostatistics at Memorial Sloan-Kettering Cancer Center, New York, and her associates said the terminally ill patients “have essentially no chance of benefiting from these procedures,” which they said were the result of a “culture of screening on ‘autopilot.’?”
They noted, however, that current guidelines “do not directly address the appropriateness of screening for individuals with terminal illnesses.”
"The most plausible interpretation of our data is that efforts to foster adherence to screening have led to deeply ingrained habits."
The screening rates were one-third to one-half the rates in a matched control population of healthy adults who were followed over the same time period. Dr. Sima and her colleagues noted that rates of unnecessary cancer screening are likely to be even higher in the general population of patients with advanced cancer, which would include younger patients and those who are commercially insured (JAMA 2010;304:1584-91).
The investigators analyzed 1998-2005 data from the Surveillance, Epidemiology, and End Results (SEER) cancer registry, which is linked with Medicare claims. They identified 87,736 Medicare patients (median age, 77 years) who survived at least 2 months after a diagnosis of advanced lung, colorectal, breast, gastroesophageal, or pancreatic cancer, and were followed until death or 2008.
Although such cancers have a median survival of less than 2 years, 15% of the men had PSA testing. About 9% of the women underwent screening mammography and 6% underwent Pap testing. Two percent of men and women underwent lower GI endoscopy screening for colorectal cancer.
The data did not indicate whether this screening was ordered by oncologists or primary care physicians, nor whether it was driven by patient demand. But “whatever the impetus, screening utilization by patients with advanced cancer adds to the mounting concern about overdiagnosis,” the researchers said.
“The most plausible interpretation of our data is that efforts to foster adherence to screening have led to deeply ingrained habits. Patients and their health care practitioners accustomed to obtaining screening tests at regular intervals continue to do so even when the benefits have been rendered futile in the face of competing risk from advanced cancer,” Dr. Sima and her associates said.
As an example of this “autopilot” screening, they noted that 20% of the study population continued to undergo regular testing of cholesterol levels even though their life expectancy was drastically limited.
Furthermore, we hypothesize that neither primary care physicians nor oncologists routinely engage in the difficult discussions that require explanation of why continuation of procedures to which patients have become accustomed is no longer necessary.
“There is substantial evidence that even when physicians recognize that life expectancy is limited, they do not consistently communicate prognosis, and patients may use denial as a coping strategy to face impending loss. Our findings represent one manifestation of this communication deficit.”
Any attempt to limit patient care “is routinely met with vocal opposition,” but this overuse of cancer screening “is likely to be relatively uncontroversial,” the investigators said.
“Each medical specialty needs to engage in thoughtful self-scrutiny to identify episodes of unnecessary care. We suggest that the road to a high-performing, high-value health care system will be paved with small stones such as the example we have identified.”
This study was supported in part by a grant from the National Cancer Institute. Dr. Sima and her colleagues did not report any financial disclosures.