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