Abstract
Guidelines recommend against routine breast and prostate cancer screenings in older adults with less than 10 years' life expectancy. One study using a claims-based prognostic index showed that receipt of cancer screening itself was associated with lower mortality, suggesting that the index may misclassify individuals when used to inform cancer screening, but this finding was attributed to residual confounding because the index did not account for functional status. To examine whether cancer screening remains significantly associated with all-cause mortality in older adults after accounting for both comorbidities and functional status. This cohort study included individuals older than 65 years who were eligible for breast or prostate cancer screening and who participated in the 2004 Health and Retirement Study. Data were linked to Medicare claims from 2001 to 2015. Data analysis was conducted from January to November 2020. A Cox model was used to estimate the association between all-cause mortality over 10 years and receipt of screening mammogram or prostate-specific antigen (PSA) test, adjusting for variables in a prognostic index that included age, sex, comorbidities, and functional status. Potential confounders (ie, education, income, marital status, geographic region, cognition, self-reported health, self-care, and self-perceived mortality risk) of the association between cancer screening and mortality were also tested. The breast cancer screening cohort included 3257 women (mean [SD] age, 77.8 [7.5] years); the prostate cancer screening cohort included 2085 men (mean [SD] age, 76.1 [6.8] years). Receipt of screening mammogram was associated with lower hazard of all-cause mortality after accounting for all index variables (adjusted hazard ratio [aHR], 0.67; 95% CI, 0.60-0.74). A weaker, but still statistically significant, association was found for screening PSA (aHR 0.88; 95% CI, 0.78-0.99). None of the potential confounders attenuated the association between screening and mortality except for cognition, which attenuated the aHR for mammogram from 0.67 (95% CI, 0.60-0.74) to 0.73 (95% CI, 0.64-0.82) and the aHR for PSA from 0.88 (95% CI, 0.78-0.99) to 0.92 (95% CI, 0.80-1.05), making PSA screening no longer statistically significant. In this study, cognition attenuated the observed association between cancer screening and mortality among older adults. These findings suggest that existing mortality prediction algorithms may be missing important variables that are associated with receipt of cancer screening and long-term mortality. Relying solely on algorithms to determine cancer screening may misclassify individuals as having limited life expectancy and stop screening prematurely. Screening decisions need to be individualized and not solely dependent on life expectancy prediction.
Highlights
IntroductionCancer screening offers potential benefits of early detection and decreased cancer-related mortality and morbidity, but these benefits are not immediate: they have been shown to have a lag time of approximately 10 years.[1,2,3,4,5,6] complications and burdens from cancer screening can occur in the short term.[2,3,4,5,6,7,8,9] Increasingly, research and clinical practice guidelines recommend that cancer screening decisions take into account a patient’s life expectancy, with the rationale that patients with limited life expectancies may be exposed to the short-term harms of screening when they are unlikely to live long enough to benefit.[2,3,4,5,6,10,11,12,13,14] Most guidelines mention that clinicians should not routinely screen patients for breast, prostate, or colorectal cancers if they have less than 10 years’ life expectancy.[6,10,11,12,13,14] the concept of using limited life expectancy to inform cancer screening is sound, how to best operationalize this concept in practice is controversial
Receipt of screening mammogram was associated with lower hazard of all-cause mortality after accounting for all index variables
A weaker, but still statistically significant, association was found for screening prostate-specific antigen (PSA)
Summary
Cancer screening offers potential benefits of early detection and decreased cancer-related mortality and morbidity, but these benefits are not immediate: they have been shown to have a lag time of approximately 10 years.[1,2,3,4,5,6] complications and burdens from cancer screening can occur in the short term.[2,3,4,5,6,7,8,9] Increasingly, research and clinical practice guidelines recommend that cancer screening decisions take into account a patient’s life expectancy, with the rationale that patients with limited life expectancies may be exposed to the short-term harms of screening when they are unlikely to live long enough to benefit.[2,3,4,5,6,10,11,12,13,14] Most guidelines mention that clinicians should not routinely screen patients for breast, prostate, or colorectal cancers if they have less than 10 years’ life expectancy.[6,10,11,12,13,14] the concept of using limited life expectancy to inform cancer screening is sound, how to best operationalize this concept in practice is controversial. The authors concluded that the specific prognostic index used in the study, which was based solely on age and comorbidity measures in administrative data, did not adequately capture important information, such as functional status, and underestimated life expectancy in those who received screening.[24] Whether receipt of cancer screening is independently associated with life expectancy when accounting for both comorbidities and functional status is unknown. This information is important both for improving life expectancy predictions in general and for informing how to use predicted life expectancy in cancer screening decision-making.
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