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Seniors face conflicting advice on cancer tests
Arthur Cohen was a healthy, active 85-year-old when his Toronto doctor recommended a colonoscopy to check for early signs of colorectal cancer.
The colonoscopy -- Cohen's first -- revealed two polyps. During surgery to remove them, the elderly man's colon was perforated and a cascade of complications followed. Cohen developed sepsis, peritonitis and kidney failure and stayed in intensive care for a full month.
Of course, most colonoscopies go smoothly -- for older as well as younger adults. Still, Cohen's son Carl, of Skokie, wonders about his dad's decision to have the procedure. "It never occurred to him that he could suffer a major quality-of-life setback," Cohen said.
As baby boomers prepare to join the 65-plus set over the next decade, medical experts are weighing the benefits and costs of cancer screenings for seniors. Mammograms for women in their 80s, colonoscopies for anyone 75 and older, and PSA ( prostate specific antigen) tests for older men are controversial.
The purpose of screenings is to detect cancer early, when treatments are most likely to be effective, and to save lives. That the tests do so for colon, breast and cervical cancer has been well-established for middle-age adults but is not indisputable for those who are older, as most studies have been done in people younger than 65. Research on routine PSA screening has yet to prove a definitive benefit at any age.
On the other side are the potential costs, which can include unnecessary treatments for cancers that never would have become life-threatening, the anxiety and distress associated with cancer diagnosis, the complications associated with screening procedures or therapies, and medical expenses.
Take colon cancer. Although detecting a polyp is advantageous at age 50, the benefits are less clear at 80. Typically, polyps take 10 to 15 years to become cancerous and potentially life-threatening, and often seniors will die of other ailments before it happens, said Dr. Neal Persky, a geriatrics specialist at the University of Michigan. But the idea that it may not be advisable for older adults to undergo cancer screenings is much debated. Some experts argue there shouldn't be firm age cutoffs because seniors aren't all alike. Some 80-year-olds are robust and can easily live another dozen years, while others have very limited life expectancies, experts said.
"As long as a person is in good health and would be a good candidate for treatment, then they are a reasonable candidate for screening," said Robert Smith, director of cancer screening at the American Cancer Society.
The influential U.S. Preventive Services Task Force, an independent group that rigorously evaluates preventive services, has suggested stricter standards. It favors ending screenings when evidence indicates most people of a certain age are more likely to die of another condition -- say, stroke or heart failure -- than of cancer. For colon cancer, it sets the bar at 86; for prostate cancer, 75. Older people are more likely to experience complications from the tests and less likely to reap benefits, said Dr. Ned Calonge, task force chairman.
Because there is no consensus, Dr. Michael Rakotz, a family doctor at NorthShore University HealthSystem in Highland Park, suggests seniors talk to their doctor and make sure they understand the relative risks and benefits of cancer screenings before making a decision. Seniors' health varies widely and "doctors have to assess these situations one at a time," he said.
If a doctor expresses doubt about getting a Pap smear or a PSA test at a certain age, don't take offense. "The message isn't, 'You're old; we're not going to waste our money on you,' but rather, 'You may not need to have these tests at this point in your life span,' " said Dr. Martin Gorbien, director of geriatrics at Rush University Medical Center.
Seniors should also ask themselves: If a test found cancer, what would I do? If you would decline chemotherapy, radiation therapy and surgery, then there's little point to the screening, said Dr. Ronan Factora, a geriatric specialist at the Cleveland Clinic.
A factor playing into the decision is that the pros and cons of screening older adults not at high risk vary by cancer type. With cervical cancer, experts are united in saying older women can stop getting Pap smears if they've had three previous tests, all with normal results, in the last 10 years or so. Those who remain sexually active with multiple partners should be tested.
Mammograms for older women are more controversial. Major groups haven't proposed an upper age limit, though the Preventive Services Task Force is planning to issue new breast cancer screening recommendations this year. Although 24 percent of invasive breast cancers occur in women 80 and older, "there is no evidence that screening women 80 and older with mammography results in reductions in mortality," stated a February editorial in the Journal of Clinical Oncology.
A fundamental premise of mammography is that "we catch a cancer that in general would kill that patient about 10 years later," said Dr. David Dershaw, director of breast imaging at Memorial Sloan-Kettering Cancer Center in New York. "In my practice, I do not recommend that women continue screening after 85 unless it is expected she would live until the age of 95."
Routine screening of healthy men for prostate cancer is not recommended at any age by the American Cancer Society or the Preventive Services Task Force, as it has not been proved whether it saves lives. Most prostate tumors are slow growing and unlikely to become dangerous, research shows.
The American Urological Association recommends that men 40 and older be offered PSA tests so long as they're likely to live at least another decade. On average, a very healthy man of 75 has a life expectancy of 14.2 years; if he is moderately healthy, it's 9.3.
With advice conflicting, physicians are "kind of left in the lurch," said Persky.
As for colon cancer, the Preventive Services Task Force recommends routine screening only for people up to age 75; after people turn 86, the group said, they should not receive colonoscopies at all. But other organizations, including the American College of Gastroenterology, don't endorse age cutoffs.
Gorbien said in clinical practice "we'd recommend a colonoscopy" to a healthy 80-year-old patient who'd never been screened. If, on the other hand, a healthy 80-year-old had a history of normal screenings, "often we say it's OK to stop."
Edith Schneider, 81, of Morton Grove had a colonoscopy this year at Evanston Hospital after her children insisted. "My internist would bring it up every year at my checkup, and I would say, 'I'm not interested.' But my kids were beside themselves with frustration, so finally I said yes."
Schneider had three polyps removed -- without complications -- and changed her diet after the test revealed she had diverticulosis, bulges in her colon that can become inflamed. "I have to say I'm glad we found that," she said.
Preventive Health Care Week As Americans debate health reform, the Chicago Tribune this week examines the benefits and challenges of preventive medicine and helps you take charge of your health.
Today in the news:
Screenings for seniors
Tuesday: Boosting immunity
Wednesday: Buyer beware
Thursday: Healthy families
Friday: Making changes stick
Saturday: A local initiative
Full coverage at chicagotribune.com/
Julie Deardorff talks about 10 things you can do to live a healthier life on WGN-Channel 9's Midday News.
The Medical Watch Team reports on how to ward off flu with a healthy diet on WGN's News at 9.