JAMA: Study uncovers 'futile' screening of terminal cancer patients
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Camelia S. Sima, MD, of Memorial Sloan-Kettering Cancer Center in New York City, and co-authors investigated the medical records of 87,736 fee-for-service Medicare enrollees who had been diagnosed with ante-mortem cancer between 1998 and 2005. All subjects were at least 65 years old at the time of diagnosis and were diagnosed with one of the following cancers: stage IIIB-IV lung, stage IV colorectal, breast, gastroesophageal or advanced stage pancreatic. These tumors were selected because they are relatively common types of cancers that have five-year survival rates below 20 percent, making screening and detection of other cancers of little likely value, the authors suggested.
Each cancer subject was randomly matched with a healthy fee-for-service Medicare enrollee of the same age, sex and race in order to compare the advanced cancer screening cohort with a control. Five types of screenings in patients diagnosed with advanced cancer were considered for the study: mammography, Papanicolaou, prostate-specific antigen (PSA), lower GI endoscopy and cholesterol. The median survival rate for the ante-mortem cancer groups after five years was 5 percent or less, except for those diagnosed with breast cancer, of which 16 percent survived five years or more.
Nine percent of women in the cancer cohort still received routine screening mammograms, while 6 percent of these women still underwent Pap testing for cervical cancer. By comparison, 22 percent of cancer-free women received mammograms, and 13 percent underwent Pap testing.
Fifteen percent of the male cancer cohort were tested for PSA compared to 27 percent of male controls. Twenty percent of the total cancer cohort underwent cholesterol testing and 1.7 percent received lower GI endoscopy, compared to 37 percent and 4.7 percent of the control group, respectively.
Overall, the cancer screening rates for patients already diagnosed with terminal cancer were between 35 and 55 percent of the screening rates for the healthy cohorts. The authors found that the strongest predictor of continued screening after terminal cancer diagnosis was whether a patient had undergone screenings before diagnosis. The study also found that individuals with higher incomes and those who were married were significantly more likely to continue to undergo cancer screening after their diagnoses. Nonwhite women diagnosed with cancer also were significantly more likely to receive mammogram screening.
The authors called into sharp question the utility of such prevalent screening of cancer patients, writing, “the case for wasteful spending … is clear and compelling. ... In an ideal healthcare system,” the authors continued, “healthcare practitioners would discontinue cancer screening for patients whose prognosis is too limited for the benefits of early detection to be realized.”
Sima and colleagues specifically discussed their findings within the context of healthcare reform and wasteful spending, saying that their results were indicative of a “culture of screening on ‘autopilot.’”
The authors acknowledged that their study design did not permit them to determine for any individual patient whether or not a test was appropriate. The authors also commented that they could not tell whether patients were practicing “denial” or whether oncologists were avoiding “difficult discussions” by not telling patients that screening for other cancers might no longer provide benefits. But the authors did say that “Each medical specialty needs to engage in self-scrutiny to identify episodes of unnecessary care,” and so as not to overexpose already sick patients to additional radiation, painful treatment and high costs.
“The more plausible interpretation of our data is that efforts to foster adherence to screening have led to deeply ingrained habits,” the authors concluded. “Patients and their healthcare practitioners accustomed to obtaining screening tests at regular intervals continue to do so even when the benefits have been rendered futile in the face of competing risk from advanced cancer.”