Using Prognosis to Make Screening Decisions
Elizabeth Eckstrom, MD, MPH
Oregon Health & Science University
Hollis Day, MD, MS
University of Pittsburgh
Objectives
• Discuss potential screening measures for older adults
• Discuss the role of life expectancy in deciding when to stop/continue screening
• Identify and utilize useful prognostic tools
Prevention- wow, that’s a lot!Do I just keep doing all this on everyone till they die?
• Prevention– flu shot– Pneumovax– Tetanus– Zoster– mammogram– Colonoscopy– DXA– exercise– Ca/ vitamin D– seat belts, exercise, diet– AAA
• Advanced directives– DPAHC– preferences for care
When should you stop screening older adults?
• When considering screening, think about the patient’s life expectancy and prognosis from other illnesses. Patient may have “competing risks” that make value of screening less
• Example: Diagnosing and treating an early breast cancer adds:– 18 months of life if you are 75– 12 months of life if you are 80– 6 months of life if you are 85
Life Expectancy Curves
Life Expectancy Curves
Mrs. Smith is 70 and healthy, when she develops breast cancer, with a 5year mortality rate of 25% (this is a later stage breast cancer)
Finding and curing her breast cancer could add 7 years of life
It is “easy” to think about life expectancy and prognosis when someone is healthy and gets a single disease, but what about an older person with multiple illnesses and poor functional status?
Study of Prognosis:
11,000 participants asked questions about diseases and functional status, followed over 4 years
Validated with a second group of subjects
-Lee, JAMA, 2006
Mr. Jones
84 years oldHas diabetesSmokes 1 ppdCan walk ½ mile
What is his prognosis?
Mr. Jones
84 years oldHas diabetesSmokes 1 ppdCan only walk one block
What is his prognosis?
How does this translate back to life expectancy for screening?
• It doesn’t translate perfectly
• But clearly, Mr. Jones with poorer functional status has less than a 50% chance of living greater than 5 years, so colonoscopy is no longer indicated for him
• Mr. Jones with better functional status has over a 50% chance of living 5 years, so you might choose to continue screening
Remaining Life Expectancy
Women
Men
Walter LC, JAMA, 2001
Guidelines and Prognosis
• No “one right answer” in diverse elderly population– Great variation in life expectancy/preferences
• More guidelines now base recommendations on prognosis rather than age alone– Cancer screening (Stop if limited life expectancy)– Diabetes Care (Higher A1c if limited life expectancy)
• Few guidelines provide tools to help clinicians estimate prognosis
ePrognosis
• Prognostic Index: A clinical tool that quantifies the contributions that various components of the history, physical exam, and laboratory findings make towards a diagnosis, prognosis, or likely response to treatment.
McGinn, JAMA, 2000
• UCSF geriatricians (led by Alex Smith) have developed a website repository of validated geriatric prognostic indices---ePrognosis
• Indices on website are designed for older people who do not have a dominant terminal illness
– For patients with a dominant terminal illness (e.g., advanced cancer, heart failure) use prognostic indices specifically designed for those diseases
Mr. A
75 y/o man with CHF, smokes, and has difficulty bathing, walking, and managing finances.
Mr. A
USPSTF Changes Affecting Your Practice
• New guidelines with geriatric component
• Consideration of how recommendations affect elderly patients