At her annual visit, the patient’s doctor asks if she plans to continue having regular mammograms for breast cancer, and then reminds her that it has been nearly 10 years since her last colon exam.
It’s 76. Hmmm.
Patient age alone may be an argument against more mammogram appointments. The independent and influential U.S. Preventive Services Task Force, at Latest draft guidelinesrecommends screening mammograms for women ages 40 to 74, but says “current evidence is insufficient to assess the balance between the benefits and harms of mammography in women ages 75 or older.”
Screening for colorectal cancer, with colonoscopy or with less invasive testing, becomes similarly questionable at advanced ages. Give it to the staff C score for those 76 to 85, which means that there is “at least moderate certainty that the net benefit is small”. The guidelines say it should only be offered selectively.
But what else is true about this hypothetical woman? Do you 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 affect their life expectancy, which in turn can make future cancer screenings either beneficial, useless, or actually harmful. The same considerations apply to a range of health decisions at older ages, including those involving drug regimens, surgeries, and other treatments and examinations.
“It doesn’t make sense to draw these lines by age,” said Dr. Stephen Woloshin, an internist and director of the Center for Medicine and Media at Dartmouth Institute. “It’s age plus other factors that limit your life.”
So, some medical societies and health advocacy groups have, slowly, begun to change their approach, basing recommendations about tests and treatments on life expectancy rather than just age.
“Life expectancy gives us more information than age alone,” said Dr. C. Lee, a geriatrician at the University of California, San Francisco. “It often leads to better decisions.”
Some of the task force’s recent recommendations reflect this broader view. For older people pass Lung cancer testsFor example, the guidelines advise considering factors such as smoking history and a “health problem that significantly limits life expectancy” in deciding when to stop screening.
The staff’s colorectal screening guidelines call for consideration of the older patient’s “health status (eg, life expectancy, co-morbid conditions), prior screening status and individual preferences.”
Similarly, the American College of Physicians incorporates life expectancy into it Prostate cancer screening guidelines; So does the American Cancer Society, in its guidelines for Breast cancer screening for women over the age of 55.
But how does that 76-year-old woman know how long she’s going to live? How does anyone know?
The average life expectancy of a 75-year-old is 12 years. But when Dr. Eric Widera, a geriatrician at the University of California, San Francisco, analyzed 2019 census data, he found a huge discrepancy.
The data shows that people of the least healthy 75 years of age, who are less than 10 percent likely to die within about three years. Those in the top 10 percent will probably live for 20 or so.
All of these projections are based on averages and cannot determine the life expectancy of individuals. But just as doctors constantly use risk calculators to decide, say, whether to prescribe medications to prevent osteoporosis or heart disease, consumers can use online tools to get ballpark estimates.
For example, Dr. Woloshin and his late wife and research partner, Dr. Lisa Schwartz, helped the National Cancer Institute develop Know Your Chances Calculatorwhich launched online in 2015. Initially, it used age, gender, 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 dying overall over a five- to 20-year period.
Institute Recently reviewed The calculator adds smoking status, which is a critical factor in life expectancy and a factor that users control, unlike other criteria.
“Personal choices are driven by priorities and concerns, but objective information can help guide those decisions,” said Dr. Barnett Kramer, an oncologist who directed the institute’s division of cancer prevention, when he published the calculator.
He called it “an antidote to some of the fear mongering that patients see all the time on TV,” courtesy of pharmaceutical companies, medical organizations, advocacy groups, and disturbing media reports. “The more information they can get from these streams, the more they can arm themselves against healthcare choices that aren’t helping them,” said Dr. Kramer. He noted that unnecessary testing can lead to overdiagnosis and overtreatment.
A number of health organizations and groups provide disease-specific calculators online. Presented by the American College of Cardiology “Risk estimation” for cardiovascular disease. The National Cancer Institute’s calculator rates risk of breast cancerMemorial Sloan Kettering Cancer Center offers one Lung Cancer.
However, calculators that look at individual diseases usually do not compare the risk with the risk of death from other causes. “They don’t give you context,” said Dr. Woloshin.
It is perhaps the broadest online tool for estimating life expectancy in older adults prognosisIt was developed in 2011 by Dr. Widera, Dr. Lee, and several other geriatricians and researchers. Designed for use by healthcare professionals but also available to consumers, it provides about two dozen validated measures of aging for estimating mortality and disability.
The calculators, some for patients who live alone and others for those in nursing homes or hospitals, include significant information about health history and current functional ability. Helpfully, there is a file Utilize time tool Shows what examinations and interventions may still be useful in a given life expectancy.
Let’s take our hypothetical 76-year-old. If sh e is a healthy smoker and has no problems with daily activities and can, among other things, walk a quarter mile without difficulty, the mortality scale on ePrognosis shows that her life expectancy makes mammography a reasonable option, regardless of what the age guidelines say.
“The danger of simply using age as a cut-off means that we sometimes age,” said Dr. Widera.
If a former smoker has lung disease, diabetes, and limited mobility, on the other hand, the calculator indicates that while she’s likely to continue taking the statin, she can finish breast cancer screening.
“Competing mortality” – the chance that another disease will cause her death before the disease being checked – means she probably won’t 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, for Medicare. Some seniors never want to stop offerings, even when the data shows that they are no longer useful.
And some are completely uninterested in discussing life expectancy; So do some of their doctors. Either party can exaggerate or underestimate the risks and benefits.
“Patients will simply say, ‘It was my uncle who lived to be 103,’” recalls Dr. Kramer. “Or if you tell someone, ‘Your chances of long-term survival are one in 1,000,’ a powerful psychological mechanism prompts people to say, ‘Thank God, I thought it was hopeless.’” I’ve seen it all the time.”
But for those seeking to make healthy decisions based on evidence-based calculations, online tools provide valuable context beyond age alone. Looking at the life expectancy, Dr. Woloshin said, “You’ll know what to focus on, rather than dreading anything on the news that day.” “It anchors you.”
The developers want patients to discuss these predictions with their medical providers, while being careful not to make decisions without their involvement.
“This is supposed to be a starting point for the talks,” said Dr. Woloshin. “It’s possible to make more informed decisions — but you need some help.”