to David Haggstrom from the Richard L. Roudebush VA Medical Center in
Indianapolis in the US and his team a significant number of physicians
would recommend colorectal cancer screening for elderly patients with a
severe illness. They say that such patients would not benefit from the
procedure and, in fact, unnecessary screening may do more harm than
good. Their worką appears online in the Journal of General
Internal Medicine˛, published by Springer.
Medical evidence does not indicate that colorectal cancer screening has
any benefit among patients with limited life expectancy. Although
guidelines recommend screening for patients aged 50 years and older,
elderly patients with severe illnesses are unlikely to benefit from
early cancer detection.
Haggstrom and colleagues explored whether colorectal cancer screening
decisions are influenced by the patient's age and state of health. They
surveyed 1,266 physicians - a mix of general internal medicine, family
practice and obstetrics-gynecology physicians - between September 2006
and May 2007. The physicians were given nine patient scenarios that
varied the patient's age and existing illness. Patient age was split
into three categories: age 50, 65 and 80. There were three underlying
illness states: healthy patient with no illness; patient with moderately
severe illness (ischemic cardiomyopathy*); and patient with severe
illness (advanced lung cancer). For each vignette, the physicians were
asked which screening test they would recommend, if any.
Overall, the more serious the underlying illness, the less likely
physicians were to recommend screening. The likelihood of recommending
screening also fell with a patient's advancing age. In addition, the
healthier the patient, the more likely physicians were to recommend more
invasive screening e.g. colonoscopy versus non-invasive tests such as
fecal occult blood testing (FOBT).
However, 25 percent of primary care physicians recommended colorectal
cancer screening for an 80-year-old patient with advanced lung cancer
who would not benefit.
Interestingly, physicians who were obstetrics-gynecology physicians were
more likely to recommend colorectal cancer screening for 80-year-old
patients with advanced lung cancer than other physicians. Physicians who
had access to electronic medical records were less likely to recommend
screening of elderly patients with severe illness.
The authors conclude: "Most physicians appear to shift their
recommendations in an appropriate manner in response to varying patient
age and underlying illness. Yet there is a significant proportion of
outliers who recommend screening among patients with limited life
expectancy, for whom screening tests have no benefit and are potentially
harmful. Further work is needed to better understand how physicians can
develop more confidence in stopping screening when there is no clinical
benefit, as well as quantifying the impact of over-screening with risky
procedures on patient outcomes."