One of the goals of an effective health care system is to provide screening that either prevents disease or detects it when treatment will improve longevity or quality of life. Screening guidelines are usually evidence-based (i.e., based upon clinical trials) or consensus-based (i.e., based upon general agreement).
Cancer screening guidelines generally recommend ages at which screening should begin, but they are often vague—or completely derelict—at specifying when screening should be discontinued.
Recommendations for cessation of cancer screening are based upon population dynamics and life expectancy statistics. Conversely, perceptions of cancer risk—or the impact of getting cancer at an advanced age after screening has been discontinued—are extremely personalized.
Ultimately, then, the decision to continue or discontinue screening must be left to each patient. This decision should be based upon an understanding of evidence-based guidelines and a discussion with a health care provider.
The number of Americans who are older than 65 years is expected to increase from its current level of 30 million to over 70 million by the year 2030. As the proportion of elderly citizens grows and the country's economy is increasingly strapped by health care costs, policy makers may be compelled to clarify guidelines for stopping cancer screening in older individuals.
Due to economic trends within the health-care industry, payment for any screening that is performed outside the parameters of evidence-based guidelines may eventually fall to the patient. At the present time, though, disagreement among the organizations that determine these parameters precludes insurance companies from unilaterally denying payment for all screening in elderly populations.
Current Guidelines for Stopping Cancer Screening
Various organizations may offer different recommendations for cessation of screening:
Breast Cancer
- American Cancer Society (ACS): Screening cessation should be individualized, “based upon potential benefits and risks of screening in the context of overall health and longevity”
- American Geriatrics Society (AGS): Breast cancer screening may continue “in women with an estimated life expectancy of at least four years”
- US Preventive Services Task Force (USPSTF): Women with “conditions that limit their life expectancy are unlikely to benefit from screening”
Colon Cancer
- USPSTF: For previously-screened individuals, “…recommends against routine screening in adults 76 to 85 years of age; recommends against all screening beyond the age of 85”
Prostate Cancer
There is ongoing debate about whether screening for prostate cancer increases or decreases morbidity or mortality. If screening is offered at all, guidelines are as follows:
- American Academy of Family Physicians (AAFP) and USPSTF: Recommends against screening beyond the age of 75
- American Urological Association (AUA) and ACS: Screening should be offered annually beginning at age 50 to men with a life expectancy of at least ten years
Cervical Cancer
- American College of Obstetricians and Gynecologists (ACOG): Screening should be “based upon a patient’s medical history and the physician’s ability to monitor the patient in the future”
- AAFP and USPSTF: Stop screening at 65 years of age if patients “have had adequate recent screening with normal Pap smears and are not otherwise at high risk”
- ACS: Discontinue at 70 years of age following “three or more normal Pap tests in a row and no abnormal Paps in the past ten years”
- AGS: Discontinue at 70 years of age; “there is little evidence for or against screening women who have been regularly screened in previous years”
(Adapted from Albert R and Clark M. Cancer screening in the older patient. Am Fam Phys 2008;78(12):1369-1374)
Screening for specific cancers has been shown to improve longevity and quality of life. Cessation of screening in older persons is currently based upon individual preference and life expectancy.
