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During her annual visit, the patient’s doctor asks her if she plans to continue having regular mammograms to screen for breast cancer, then reminds her that it has been almost 10 years since her last colonoscopy.
She is 76 years old. Hmm.
The patient’s age alone can be an argument against further mammography appointments. The Independent and Influential American Task Force on Preventive Services, in its latest draft guidelinesrecommends screening mammograms for women aged 40 to 74, but states that “current evidence is insufficient to assess the balance between the benefits and harms of screening mammography in women aged 75 or older”.
Screening for colorectal cancer, through a colonoscopy or a less invasive test, also becomes questionable in old age. The working group gives him a C grade for 76 to 85 year olds, which means that there is “at least moderate certainty that the net benefit is low”. It should only be offered selectively, according to the guidelines.
But what else is true about this hypothetical woman? Does she play tennis twice a week? Does she have heart disease? Did his parents live well until they were 90? Does she smoke?
Any or all of these factors affect their life expectancy, which could make future cancer screenings helpful, unnecessary or even harmful. The same considerations apply to a range of health decisions at later ages, including those involving drug regimens, surgeries, other treatments, and screenings.
“It doesn’t make sense to draw these lines by age,” said Dr. Steven Woloshin, internist and director of the Center for Medicine and Media at the Dartmouth Institute. “It’s age and other factors that limit your life.”
Slowly, therefore, some medical associations and health advocacy groups have begun to change their approaches, basing their test and treatment recommendations on life expectancy rather than simply age.
“Life expectancy gives us more information than age alone,” said Dr. Sei Lee, a geriatrician at the University of California, San Francisco. “It leads to better decision making more often.”
Some recent task force recommendations already reflect this broader vision. For older people experiencing lung cancer testsfor example, the guidelines advise considering factors such as a history of smoking and “a health condition that significantly limits life expectancy” in deciding when to discontinue screening.
The Colorectal Screening Task Force guidelines call for consideration of “an elderly patient’s health status (eg, life expectancy, comorbid conditions), prior screening status, and individual preferences.”
Similarly, the American College of Physicians incorporates life expectancy into its prostate cancer screening guidelines; the same goes for the American Cancer Society, in its guidelines for breast cancer screening for women over 55.
But how does this 76-year-old woman know how long she will live? How does anyone know?
A 75 year old has an average life expectancy of 12 years. But when Dr. Eric Widera, a geriatrician at the University of California, San Francisco, analyzed the 2019 census data, he found huge variations.
The data shows that the least healthy 75-year-olds, those in the bottom 10%, would likely die in about three years. Those in the top 10% would probably live another 20% or so.
All of these predictions are based on averages and cannot determine the life expectancy of individuals. But just as doctors constantly use risk calculators to decide, for example, whether to prescribe drugs to prevent osteoporosis or heart disease, consumers can use online tools to get rough estimates.
For example, Dr. Woloshin and his late wife and research partner, Dr. Lisa Schwartz, helped the National Cancer Institute develop Calculator Know Your Oddswhich was posted online in 2015. Initially, it used age, sex and race (but only two, black or white, due to limited data) to predict the odds of dying from specific common diseases and the odds of overall mortality over a five to 20-year period.
The Institute recently overhauled the calculator to add smoking status, a critical factor in life expectancy and over which, unlike other criteria, users have some control.
“Personal choices are driven by priorities and fears, but objective information can help inform those decisions,” said Dr. Barnett Kramer, an oncologist who led the institute’s Division of Cancer Prevention when the calculator was released.
He called it “an antidote to some of the scare campaigns patients see on TV all the time,” courtesy of drugmakers, medical organizations, advocacy groups and scaremongering media reports. “The more information they can glean from these charts, the more they can guard against health care choices that don’t help them,” Dr. Kramer said. Unnecessary testing, he pointed out, can lead to overdiagnosis and overtreatment.
A number of health facilities and groups provide disease-specific online calculators. The American College of Cardiology offers a “risk estimator” for cardiovascular disease. A calculator from the National Cancer Institute assesses breast cancer riskand Memorial Sloan Kettering Cancer Center offers one for lung cancer.
However, calculators that look at single diseases generally do not compare the risks to those of mortality from other causes. “They don’t give you the context,” Dr. Woloshin said.
Probably the most comprehensive online tool for estimating the life expectancy of older people is ePrognosis, developed in 2011 by Dr. Widera, Dr. Lee and several other geriatricians and researchers. Intended for health professionals but also accessible to consumers, it offers around twenty validated geriatric scales for estimating mortality and disability.
The calculators, some for patients living alone and others for those living in nursing homes or hospitals, incorporate considerable information about medical history and current functional ability. Fortunately, there is a “time to benefit” instrument which illustrates which screenings and interventions may still be useful at specific life expectancies.
Consider our hypothetical 76-year-old man. If it’s a healthy person who never smokes, has no problems with daily activities, and is able to walk a quarter mile without difficulty, among other things, a mortality scale on ePrognosis shows that their extended life expectancy makes mammography a reasonable choice, regardless of what the age guidelines say.
“The risk of just using age as a threshold means that we sometimes under-treat” very healthy older people, Dr. Widera said.
If she’s a former smoker with lung disease, diabetes and limited mobility, on the other hand, the calculator says that while she should probably continue taking a statin, she can end breast cancer screening.
“Concurrent mortality” – the possibility of another disease causing her death before the one she was screened for – means she is unlikely to live long enough to see a benefit.
Of course, patients will continue to make their own decisions. Life expectancy is a guide, not a limit to medical care. Some older people I don’t want to stop the screenings anymoreeven when the data shows that they are no longer useful.
And some have exactly no interest in discussing their life expectancy; just like some of their doctors. Either party can overestimate or underestimate the risks and benefits.
“Patients will simply say, ‘I had a great-uncle who lived to be 103,'” Dr. Kramer recalls. “Or if you say to someone, ‘Your long-term chance of survival is one in 1,000,’ a powerful psychological mechanism causes people to say, ‘Oh thank God, I thought that was hopeless.’ I saw it all the time.
But for those looking to make health decisions on evidence-based calculations, online tools provide valuable context beyond age alone. Given the projected life expectancy, “you’ll know what to focus on, instead of being scared off by whatever’s in the news that day,” Dr. Woloshin said. “It anchors you.”
However, the developers want patients to discuss these predictions with their medical providers and caution against making decisions without their involvement.
“This is meant to be a starting point” for conversations, Dr. Woloshin said. “It’s possible to make much more informed decisions, but you need help.”
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