At her annual visit, the patient’s doctor asked her if she would continue to have regular mammograms to check for breast cancer, and reminded her that it had been nearly a decade since her last colonoscopy.
She is 76 years old. Hmm.
Patient age alone can be an argument against scheduling further mammography. The independent and influential U.S. Preventive Services Task Force, Latest draft guidelinesrecommends mammography screening for women aged 40 to 74 years, but states that “there is insufficient current evidence to assess the balance of benefits and harms of mammography screening for women aged 75 years and older.”
Screening for colorectal cancer with colonoscopy and less invasive tests is similarly questionable in older people.the task force gives it Ages 76-85 are grade CThis means that there is “at least moderate certainty that the net profit will be small.” The guidelines state that it should only be offered selectively.
But what else is true about this fictional woman? Does she play tennis twice a week? Does she have heart disease? Did her parents live well into their 90s? does she smoke?
Any or all of these factors could affect her life expectancy and make future cancer screenings beneficial, irrelevant, or actually harmful. The same considerations apply to many health decisions for older people, such as medication regimens, surgery, other treatments and screenings.
“It doesn’t make sense to draw a line by age,” says Dr. Stephen Wolthin, an internist and director of the Center for Medicine and Media at the Dartmouth Institute. “It’s your age and other factors that limit your life.”
As a result, some medical associations and health advocacy groups are gradually changing their approach, making recommendations for testing and treatment based on life expectancy rather than simply age.
“Life expectancy is more informative than age alone,” says Dr. Say Lee, a geriatrician at the University of California, San Francisco. “It will lead to better decisions being made more often.”
Some recent Task Force recommendations already reflect this broader view.For older people undergoing treatment lung cancer testFor example, the guidelines advise considering factors such as smoking history and “health problems that substantially limit lifespan” when deciding when to stop screening.
The task force’s colorectal screening guidelines call for consideration of the elderly patient’s “health status (life expectancy, comorbidities, etc.), prior screening status, and personal preferences.”
The American College of Physicians likewise incorporates life expectancy into its metric. Prostate Cancer Screening Guidelinesthe American Cancer Society says in its guidelines as well. Breast cancer screening for women aged 55 and over.
But how does the 76-year-old woman know her life expectancy?
Life expectancy at age 75 is 12 years. But when Dr. Eric Weidera, a geriatrician at the University of California, San Francisco, analyzed the 2019 Census data, he found wide variation.
Data show that the poorest 75-year-olds, those in the bottom 10 percent, are likely to die within about three years. The top 10% will probably live another 20 years.
All of these projections are based on averages and cannot accurately determine an individual’s life expectancy. But just as doctors routinely use risk calculators to decide whether to prescribe drugs to prevent osteoporosis or heart disease, for example, consumers can use online tools to get rough estimates.
For example, Dr. Woloshin and his late wife and research partner, Dr. Lisa Schwartz, contributed to the development of the National Cancer Institute. Calculator to know your chanceswent online in 2015. Initially, age, gender, and race (but only two of him, black or white, due to limited data) were used to predict the probability of dying from certain common diseases and overall mortality over time periods of 5 to 20 years.
Institute recently revised Calculation tool for adding smoking status. It is an important factor in life expectancy and, unlike other criteria, is under some control by the user.
“Priorities and fears drive individual choices, but objective information helps inform those decisions,” said Barnett Kramer, Ph.D., an oncologist who led the Institute’s Cancer Prevention Division when the calculator was unveiled.
Courtesy of pharmaceutical companies, medical groups, advocacy groups and alarming media coverage, he called it “an antidote to some of the fear-mongering campaigns patients see on TV all the time.” “The more information we gather from these tables, the more armed we can be against unhelpful medical choices,” Dr. Kramer said. Unnecessary testing can lead to overdiagnosis and overtreatment, he said.
Many medical institutions and organizations offer disease-specific online calculators.What the American College of Cardiology Offers Cardiovascular Disease “Risk Estimation Tool”. The National Cancer Institute calculator evaluates: breast cancer riskMemorial Sloan Kettering Cancer Center, lung cancer.
But calculators that look at a single disease don’t usually compare that risk with the risk of death from other causes. “They don’t give you context,” says Dr. Wolothin.
Perhaps the most extensive online tools for estimating life expectancy for older people are: prognosis, developed in 2011 by Dr. Weidera, Dr. Lee, and several other geriatricians and researchers. Intended for use by health professionals, but also available to consumers, it offers approximately 24 validated geriatric scales that estimate mortality and disability.
Calculators, such as those for patients living alone and those in nursing homes and hospitals, incorporate considerable information about their health history and current functional capabilities. It is useful to Means of “Time to Profit” This indicates which screens and interventions will remain useful for a given life expectancy.
Consider a hypothetical age of 76. If she is a healthy non-smoker, has no problems with her daily activities, and is able to walk a quarter mile with ease, the ePrognosis mortality scale indicates that mammography is a reasonable choice because her life expectancy is increasing, regardless of age guidelines.
“Age-based risk alone means that healthy older people may be undertreated,” Dr. Weidera said.
On the other hand, if she’s an ex-smoker and has lung disease, diabetes, or limited mobility, the calculator shows she can probably stop taking statins, but can stop breast cancer screening.
“Competing mortality”, the chance that another disease will cause her death before the one tested for, means that she probably won’t live long enough to benefit from it.
Of course, patients will continue to make their own decisions. Life expectancy is a guideline, not a medical limit. Some older people never want to stop testing, even when data show that testing no longer helps.
Others are completely uninterested in discussing their life expectancy. So do some doctors. Either party may overestimate or underestimate the risks and benefits.
“Patients just say, ‘I had a great uncle who lived to be 103,'” Dr. Kramer recalls. “Or, if you say to someone, ‘The chances of long-term survival are 1 in 1,000,’ there’s a powerful psychological mechanism that makes people say, ‘Oh, thank God, I thought I was hopeless.’ I’ve been watching.”
But for those trying to make health decisions based on evidence-based calculations, online tools provide valuable context beyond age alone. Given the expected life expectancy, “you’ll know what to focus on instead of being horrified by the news of the day,” says Dr. Wolothin. “It locks you in.”
However, the developers do ask that patients discuss these projections with their healthcare providers, and caution against making decisions without their providers’ involvement.
“This is meant to be a conversation starter,” said Dr. Wolothin. “It is possible to make more informed decisions, but we need help.”