Journal of General Internal Medicine

, Volume 28, Issue 2, pp 292–298 | Cite as

Individualizing Cancer Screening in Older Adults: A Narrative Review and Framework for Future Research

  • Elizabeth EckstromEmail author
  • David H. Feeny
  • Louise C. Walter
  • Leslie A. Perdue
  • Evelyn P. Whitlock


Older adults often have multiple chronic conditions that may decrease additional life expectancy. Research evaluating the benefits and harms of screening must include consideration of competing morbidities and patient heterogeneity (beyond age), potentially increased harms of screening, and patient preferences. Other areas in need of additional research include the lack of evidence for older adults on the harms of screening tests; the overdiagnosis of disease; the burden of disease labeling; the effects of inaccurate test results; the harms of disease treatment; and harms related to prioritization of healthcare (e.g., for a particular patient, lifestyle counseling may be more important than screening). Nontraditional outcomes, such as the effects on family caregivers, are also relevant. Studies comparing trajectories of quality-adjusted survival with and without screening to assess net benefit are typically lacking. There is little evidence on the preferences of older adults for deciding whether to be screened, the process of being screened, and the health states associated with being or not being screened. To enhance the quality and quantity of evidence, older adults need to be enrolled in screening trials and clinical studies. Measures of functional status and health-related quality of life (HRQL) need to be included in trials, registries, and cohort studies. This article addresses these challenges, and presents a framework for what research is needed to better inform screening decisions in older adults.


older adults cancer screening patient preferences 




Dr. Erica S. Breslau, PhD at the National Cancer Institute, Dr. Roger Chou, MD at Oregon Health and Science University, Dr. Bruce Kinosian, MD at the University of Pennsylvania, Dr. Tracy Wolff, MD, MPH at the Agency for Healthcare Research and Quality, and Tracy Beil, MS and Debra Burch at the Center for Health Research.


Agency for Health Care Research; National Cancer Institute (Dr. Eckstrom, Dr. Feeny, and Ms. Perdue). Dr. Walter’s effort was supported by the National Cancer Institute (grant number R01 CA134425) and the National Institute on Aging (grant number K24AG041180).

Prior Presentations

1st Annual Healthy Aging Conference of the Healthy Aging Alliance, Portland, OR, October 27, 2011; 64th Annual Scientific Meeting, The Gerontological Society of America, Boston, MA, November 18–22, 2011.

Conflict of Interest

David H. Feeny has a proprietary interest in Health Utilities Incorporated, Dundas, Ontario, Canada. HUInc. distributes copyrighted Health Utilities Index (HUI) materials and provides methodological advice on the use of HUI. The other authors declare that they do not have a conflict of interest to report.


  1. 1.
    Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008;149(9):627–37.Google Scholar
  2. 2.
    Nelson HD, Tyne K, Naik A, et al. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med. 2009;151(10):727–42.PubMedGoogle Scholar
  3. 3.
    US Preventive Services Task Force. Screening for Cervical Cancer: Recommendations and Rationale. Agency for Healthcare Research and Quality; 2003. Accessed September 7, 2012.
  4. 4.
    Leipzig RM, Whitlock EP, Wolff TA, et al. Reconsidering the approach to prevention recommendations for older adults. Ann Intern Med. 2010;153(12):809–14.PubMedGoogle Scholar
  5. 5.
    Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 2001;285(21):2750–6.PubMedCrossRefGoogle Scholar
  6. 6.
    Reuben DB. Medical care for the final years of life: “when you’re 83, it’s not going to be 20 years”. JAMA. 2009;302(24):2686–94. doi: 10.1001/jama.2009.1871.PubMedCrossRefGoogle Scholar
  7. 7.
    Clarfield AM. Screening in frail older people: an ounce of prevention or a pound of trouble? J Am Geriatr Soc. 2010;58(10):2016–21.PubMedCrossRefGoogle Scholar
  8. 8.
    Yourman LC, Lee SJ, Schonberg MA, et al. Prognostic indices for older adults: a systematic review. JAMA. 2012;307(2):182–92. doi: 10.1001/jama.2011.1966.PubMedCrossRefGoogle Scholar
  9. 9.
    Gill TM. The central role of prognosis in clinical decision making. JAMA. 2012;307(2):199–200. doi: 10.1001/jama.2011.1992.PubMedCrossRefGoogle Scholar
  10. 10.
    Lee S, Smith A, Widera E, et al. ePrognosis: Estimating Prognosis for Elders. 2012. Accessed August 15, 2012.
  11. 11.
    Lewis CL, Kistler CE, Amick HR, et al. Older adults’ attitudes about continuing cancer screening later in life: a pilot study interviewing residents of two continuing care communities. BMC Geriatr. 2006;6:10.PubMedCrossRefGoogle Scholar
  12. 12.
    Pignone M, Rich M, Teutsch SM, et al. Screening for colorectal cancer in adults at average risk: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137(2):132–41.PubMedGoogle Scholar
  13. 13.
    Whitlock E, Lin J, Liles E, et al. Screening for Colorectal Cancer: an Updated Systematic Review. AHRQ. 08-05124-EF-1. Rockville, Maryland: Agency for Healthcare Research and Quality; 2008.Google Scholar
  14. 14.
    Ure T, Dehghan K, Vernava AM III, et al. Colonoscopy in the elderly. Low risk, high yield. Surg Endosc. 1995;9(5):505–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Chou R, Dana T, Bougatsos C, et al. Treatments for Localized Prostate Cancer: Systematic Review to Update the 2002 U.S. Preventive Services Task Force Recommendation. Agency for Healthcare Quality and Research; 2011.Google Scholar
  16. 16.
    Mandelblatt JS, Cronin KA, Bailey S, et al. Effects of mammography screening under different screening schedules: model estimates of potential benefits and harms. Ann Intern Med. 2009;151(10):738–47.PubMedGoogle Scholar
  17. 17.
    U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. Baltimore: Williams & Wilkins; 1996.Google Scholar
  18. 18.
    Berg AO, Allan JD, Frame P, et al. Screening for Cervical Cancer: Recommendations and Rationale. AHRQ Pub. No. 03-515A. Rockville,Maryland: US Preventive Services Task Force: 2003.Google Scholar
  19. 19.
    Walter LC, Lindquist K, Nugent S, et al. Impact of age and comorbidity on colorectal cancer screening among older veterans. Ann Intern Med. 2009;150(7):465–73.PubMedGoogle Scholar
  20. 20.
    Huang ES, Zhang Q, Gandra N, et al. The effect of comorbid illness and functional status on the expected benefits of intensive glucose control in older patients with type 2 diabetes: a decision analysis. Ann Intern Med. 2008;149(1):11–9.PubMedGoogle Scholar
  21. 21.
    Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002;162(20):2269–76.PubMedCrossRefGoogle Scholar
  22. 22.
    Lin JS, O’Connor E, Whitlock EP, et al. Behavioral counseling to promote physical activity and a healthful diet to prevent cardiovascular disease in adults: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;153(11):736–50.PubMedGoogle Scholar
  23. 23.
    Yates LB, Djousse L, Kurth T, et al. Exceptional longevity in men: modifiable factors associated with survival and function to age 90 years. Arch Intern Med. 2008;168(3):284–90.PubMedCrossRefGoogle Scholar
  24. 24.
    Khaw KT, Wareham N, Bingham S, et al. Combined impact of health behaviours and mortality in men and women: the EPIC-Norfolk prospective population study. PLoS Med. 2008;5(1):e12.PubMedCrossRefGoogle Scholar
  25. 25.
    Litwin MS, Talcott JA. Measuring quality of life in prostate cancer: progress and challenges. In: Lipscomb J, Gotay CC, Snyder C, eds. Outcomes Assessment in Cancer: Measures, Methods, and Applications. New York: Cambridge University Press; 2005:126–59.Google Scholar
  26. 26.
    Patrick DL, Erickson P, eds. Health Status and Health Policy: Quality of Life in Health Care Evaluation and Resource Allocation. New York: Oxford University Press; 1993.Google Scholar
  27. 27.
    Steinwachs DM, Wu AW, Cagney KA. Outcome research and quality of care. In: Spilker BF, ed. Quality of Life and Pharmacoeconomics in Clinical Trials. Philadelphia: Lippincott-Raven Press; 1996:747–52.Google Scholar
  28. 28.
    Osoba D, King M. Meaningful differences. In: Fayers P, Hays R, eds. Assessing Quality of Life in Clinical Trials. 2nd ed. Oxford: Oxford University Press; 2005:243–57.Google Scholar
  29. 29.
    Braithwaite RS. Can life expectancy and QALYs be improved by a framework for deciding whether to apply clinical guidelines to patients with severe comorbid disease? Med Decis Making. 2011;31(4):582–95.Google Scholar
  30. 30.
    Stout NK, Rosenberg MA, Trentham-Dietz A, et al. Retrospective cost-effectiveness analysis of screening mammography. J Natl Cancer Inst. 2006;98(11):774–82. doi: 10.1093/jnci/djj210.PubMedCrossRefGoogle Scholar
  31. 31.
    Jaagosild P, Dawson NV, Thomas C, et al. Outcomes of acute exacerbation of severe congestive heart failure: quality of life, resource use, and survival. SUPPORT Investigators. The study to understand prognosis and preferences for outcomes and risks of treatments. Arch Intern Med. 1998;158(10):1081–9.PubMedCrossRefGoogle Scholar
  32. 32.
    U.S. Preventive Services Task Force. Grade Definitions. 2008. Accessed September 7, 2012.
  33. 33.
    Sheridan S, Harris R, Woolf S, et al. Shared Decisionmaking about Screening and Chemoprevention a Suggested Approach from the U.S. Preventive Services Task Force Background Article. 2011. Accessed September 7, 2012.
  34. 34.
    Quanstrum KH, Hayward RA. Lessons from the mammography wars. N Engl J Med. 2010;363(11):1076–9. doi: 10.1056/NEJMsb1002538.PubMedCrossRefGoogle Scholar
  35. 35.
    Kistler CE, Lewis CL, Amick HR, et al. Older adults’ beliefs about physician-estimated life expectancy: a cross-sectional survey. BMC Fam Pract. 2006;7:9.PubMedCrossRefGoogle Scholar
  36. 36.
    Smyth KA. Current practices and perspectives on breast cancer screening and treatment in older women with dementia. J Am Geriatr Soc. 2009;57(Suppl 2):S272–4.PubMedCrossRefGoogle Scholar
  37. 37.
    Fried TR, McGraw S, Agostini JV, et al. Views of older persons with multiple morbidities on competing outcomes and clinical decision-making. J Am Geriatr Soc. 2008;56(10):1839–44.PubMedCrossRefGoogle Scholar
  38. 38.
    Yabroff KR, Zapka J, Klabunde CN, et al. Systems strategies to support cancer screening in U.S. primary care practice. Cancer Epidemiol Biomarkers Prev. 2011;20(12):2471–9. doi: 10.1158/1055-9965.EPI-11-0783.PubMedCrossRefGoogle Scholar
  39. 39.
    Mathieu E, Barratt A, Davey HM, et al. Informed choice in mammography screening: a randomized trial of a decision aid for 70-year-old women. Arch Intern Med. 2007;167(19):2039–46.PubMedCrossRefGoogle Scholar
  40. 40.
    University of California San Francisco. UCSF CaPSURE(TM) Cancer of the Prostate Strategic Urologic Research Endeavor. 2011. Accessed September 7, 2012.
  41. 41.
    Huang GJ, Sadetsky N, Penson DF. Health related quality of life for men treated for localized prostate cancer with long-term followup. J Urol. 2010;183(6):2206–12.PubMedCrossRefGoogle Scholar
  42. 42.
    Staquet M, Berzon R, Osoba D, et al. Guidelines for reporting results of quality of life assessments in clinical trials. Qual Life Res. 1996;5(5):496–502.PubMedCrossRefGoogle Scholar
  43. 43.
    Lee CW, Chi KN. The standard of reporting of health-related quality of life in clinical cancer trials. J Clin Epidemiol. 2000;53(5):451–8.PubMedCrossRefGoogle Scholar
  44. 44.
    Brundage M, Bass B, Davidson J, et al. Patterns of reporting health-related quality of life outcomes in randomized clinical trials: implications for clinicians and quality of life researchers. Qual Life Res. 2010;20(5):653–64.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  • Elizabeth Eckstrom
    • 1
    Email author
  • David H. Feeny
    • 2
  • Louise C. Walter
    • 3
    • 4
  • Leslie A. Perdue
    • 2
  • Evelyn P. Whitlock
    • 2
  1. 1.Department of Medicine, Division of General Internal Medicine & GeriatricsOregon Health & Science UniversityPortlandUSA
  2. 2.Center for Health Research, Kaiser Permanente NorthwestPortlandUSA
  3. 3.Department of Medicine, Division of GeriatricsUniversity of California, San FranciscoSan FranciscoUSA
  4. 4.San Francisco VA Medical CenterSan FranciscoUSA

Personalised recommendations