Many health providers, including geriatricians, rely on — among other sources — guidance from the U.S. Preventive Services Task Force, an independent panel of experts in primary health care and prevention. Its members analyze population studies on the efficacy of screening and treatment for a broad range of diseases, and periodically update and release recommendations.
While there is no universal consensus (specialty groups, such as the American Cancer Society, don’t always agree with the recommendations), its guidance nevertheless often provides valuable input into decision-making.
“We know about the recommendations, but when you are one-on-one with a patient, you have to think about how the patient fits into the guidelines,” says Matthew Shuster, a Boston-area geriatrician and primary care physician. “When you are in the room with that one patient, there are a lot of factors to consider about what tests to choose.”
No single set of rules exists for stopping (or continuing) a specific test after a certain age, and medical judgments also should always consider such factors as health status and medical history, experts say.
“When people are younger — in their 40s, 50s, 60s, or when they are children — they hit certain milestones and behave in certain [consistent] ways,” says Christine Kistler, associate professor of geriatrics at the University of North Carolina School of Medicine. “But life is like a prism. We start out with clear light, but end up with different colors. By the time you hit your 70s and 80s, things happen that make you different from others of the same age. More and more, as we get older, we need to individualize medical care.”
Sometimes the dangers of doing a test on an elderly person and its aftermath can be greater than its potential benefits. Often, a patient’s health weighs into whether a clinician will suggest a test, since worrisome results can lead to debilitating treatments, including chemotherapy and surgery.
Suggesting a colonoscopy, for example, an invasive examination to detect precancerous polyps in the colon, isn’t always the right decision for an older patient in ill health. “Putting someone with a serious health issue through a colonoscopy — when it can take a decade for a polyp to develop into a cancer — means we may be subjecting them to harm now for limited benefits later,” Kistler says.
But some tests — the Pap smear, for example, which looks for cervical cancer — can safely end in women 65 and older who have a history of negative results. “That’s why screening at younger ages is so important,” Kistler says.
Aging patients still should have an annual “wellness” visit to check blood pressure, blood sugar (for the presence of Type 2 diabetes), cholesterol, bone density (for osteoporosis), obesity and underweight (for frailty), skin (for cancerous lesions), hearing, vision and balance (to evaluate the risk of falls), and cognition. They also should keep up with certain vaccinations, such as flu, shingles, tetanus and pneumonia.
But they might be able to avoid certain tests if past results consistently have been trouble-free, experts say.
“Between the ages of 50 to 75 is when you should have the majority of your screenings,” says Lisa Tank, a geriatrician and chief medical officer at Hackensack University Medical Center in Hackensack, N.J. “If you invest in those early on, the likelihood of having difficult discussions [about whether to have them] later on will be minimal.”
The major ones to consider, which all screen for cancer, include:
This test involves scraping cells from a woman’s cervix to look for early signs of cervical cancer and human papillomavirus (HPV), a sexually transmitted virus and this cancer’s primary cause. Experts agree that women 65 and older with a history of negative screenings no longer need them.
“As women get older, there is less and less cervical cancer, and the chances of having it over 65 with numerous negative tests in the past are exceedingly low,” Takahashi says.
Also, the vaccine that prevents HPV infection will probably reduce the incidence of this disease in the future.
“If you are screened regularly, and are negative, that’s a happy one to give up,” says Laurie Jacobs, a New Jersey geriatrician and a past president of the American Geriatrics Society.
Everyone hates this one. It requires drinking copious amounts of a nasty-tasting solution the day before to prompt cleansing of the colon. The procedure, performed under sedation, involves the physician threading a flexible tube with a camera through the colon to look for precancerous polyps. The polyps can take as long as 10 years to develop into cancer. Removing them eliminates the risk.
But a colonoscopy is not risk-free, especially for the elderly.
“As you age, your skin becomes thinner, so the risk of colon perforation increases,” Takahashi says. “Also, colonoscopy involves anesthesia, so patients sometimes can experience confusion or delirium. It doesn’t happen very often, but people need to be aware of it. With this test, if I can’t say you’re going to live longer if we do it, it doesn’t make any sense to push it.”
In someone 75 or older in good health and highly functional, and who will probably live for another 10 or more years, “the risk of harm from a colonoscopy is outweighed by the benefits of preventing a cancer they may experience later,” Kistler says.
The preventive services task force recommends that screening start at age 50 and continue through age 75, and then leaves it up to the patient and doctor to decide whether more screening is needed. The American Cancer Society agrees.
PSA blood test
Whether men 70 and older should have the prostate-specific antigen test — which suggests possible prostate cancer — remains controversial.
The preventive services task force says the decision for men ages 55 to 69 is an individual one determined by a patient and his doctor. After age 70, the task force recommends against the test.
Most experts agree there is little evidence that PSA screening at older ages helps men live longer. Moreover, diagnosis and treatment — which can include biopsy, surgery, and radiation — can produce unwelcome side effects, such as impaired sexual functioning.
“A lot of men may have prostate cancer, but won’t die of it,” Takahashi says. “I usually tell most men older than 75 that we don’t have good evidence taking this test will help you, and it’s definitely not a routine thing we do.”
This can be another tough one, since the risk of breast cancer rises with age.
For women 50 to 74, the preventive services task force recommends biennial mammograms but it provides no suggestions for women older than 75. The American Cancer Society says that women 55 and older should have annual or biennial mammograms, and they should keep having them if they are healthy and likely to live at least 10 or more years.
“Women in good health with longevity should have them, if they can tolerate breast surgery,” Jacobs says. “There is no point in doing the test in someone who is not going to accept treatment.”
On the other hand, deciding against having a mammogram past 75 also might be okay.
“As women age, you oftentimes will find cancers that will not cause problems,” Kistler says. “Should we then be subjecting women to surgeries, treatments and their side effects?”
Shuster agrees. “In older women, the outcomes are usually better,” he says. “The cancers may be slower growing. Mammography may find more disease, but are you really doing more good or harm by treating that disease at an older age? The same can be said of prostate cancer. People may have cancer, but they don’t always die of it.”
In short, these choices are not always easy.
“If you are an older patient and really ill, with a limited life expectancy, you won’t get a lot of benefit from a mammogram or a colonoscopy,” Shuster says. “The harder decision is whether you should continue if you are a healthy older person.”
In the latter instance, patients always should talk to their physicians, experts say.
“I worry that people will reach a certain age and just stop,” Kistler says. “I think it’s important to individualize testing for each person, and always be mindful that appropriate care does change as we age.”