Cancer screening on autopilot in patients with advanced cancer

by Alex Smith, MD

I used to get Sports Illustrated, and my favorite column was titled, “This week’s sign that the apocalypse Is upon us.”  Well, JAMA recently published the medical equivalent.

Sima and colleagues at Memorial Sloan Kettering used a population based dataset of patients with cancer to compare rates of cancer screening (mammography, PAP smears, PSA tests, colonoscopy) between patients who had advanced, incurable cancer (lung, colorectal, gastroesophageal, and breast cancers) and patients who did not have cancer.

Results:

  • mammography: 9% among patients with advanced cancer vs. 22% among patients without cancer
  • PAP smears: 6% vs. 13%
  • PSA testing: 15% vs. 27%
  • colonoscopy: 2% vs. 5%

The good news – the rates are not equal.  At least a few docs are thinking enough to not screen patients with advanced incurable cancer for another cancer!

The bad news – screening rates among patients with cancer are about a third to two-thirds of the rates of patients without cancer!  Keep in mind people need to live about 5 years in order to benefit from cancer screening.  Patients in this study had a life expectancy of less than 2 years at the time they were screened, and less than 5% overall lived more than 5 years.

The biggest predictor of continued screening after diagnosis with cancer was a history of cancer screening before diagnosis.  The authors hypothesize that docs put patients on “autopilot” cancer screening, and then don’t stop.  They write:

Furthermore, we hypothesize that neither primary care physicians nor oncologists routinely engage in the difficult discussions that require explanation of why continuation of procedures to which patients have become accustomed to is no longer necessary. There is substantial evidence that even when physicians recognize that life expectancy is limited, they do not consistently communicate prognosis, and patients may use denial as a coping strategy to face impending loss. Our findings represent one manifestation of this communication deficit.

Exactly.  We need to train providers to have these difficult conversations, create health systems that flag patients with limited life expectancy who are receiving potentially harmful tests and interventions of little benefit, and educate the public about the harms of overtesting and overtreatment.  The last is critical, because the hue and cry must come from the people — not the doctors — to instigate change.

But change we must.  Because what we’re doing is just dumb medicine.  This week’s sign that the apocalypse is upon us.

Alex Smith is an Assistant Professor of Medicine, Department of Medicine, Division of Geriatrics at the University of California, San Francisco who blogs at GeriPal.

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  • stitch

    What we have here is a failure to think. Thank you for posting this.

  • sarah

    I’d like to point out that sometimes doctors seem to be in denial too. I have metastatic colon cancer. My oncologist is clear that my prognosis is well under two years, and yet my primary care provider insisted on Pap smears and other screening tests (and also denied useful medications that might slightly increase my twenty-year risk of getting a second cancer, a risk that my oncologist said I did not need to consider).

    When I brought this up with my PCP, he said, “There is hope,” and dragged his feet about following my oncologist’s recommendations. I changed doctors. What else can you do when a PCP believes that his “hope” trumps medical statistics and the patient’s preferences?

    • MarylandMD

      Sarah,

      I am sorry to hear about your cancer and the prognosis. I wish you the best of luck in your treatment, and I hope you go well beyond your oncologist’s estimate. Thank you for your thoughts. I find the perspective of patients such as yourself very very helpful in my understanding of the patient experience.

      Just a thought: perhaps you could request your oncologist **clearly state** in the consultation notes that your prognosis is well under 2 years and he/she recommends against any routine cancer screening tests? As a PCP, I have sometimes found that oncology notes are chock full of information about gene mutations and chemotherapy protocols (which are important but not that useful to me), but are a bit weak on kinds of information (like prognosis and monitoring) that I would find really helpful.

      This is not to defend the actions of your prior PCP. If you clearly declined cancer screening, the PCP should have backed off.

      Again, thank you for your comments, and I wish you all the best.

      • stitch

        Honestly, a good primary care physician should know that a person with metastatic colon cancer is not going to have the usual life expectancy. The five year survival rate is less than 5%. The predictive value of a Pap smear (when done sequentially) is 5 years, so the value of doing a Pap is extremely low; not only that, but what would the primary care doc do if an abnormal Pap was found?

        As a primary care doc, I’ve had many patients diagnosed with serious, life threatening illnesses, not just limited to cancer. As they proceed with the acute treatment, I discuss with them putting off “routine” screening and dealing with acute, acute on chronic, and maintenance issues when they arise. Once they are done with the treatment (breast cancer, for example) then we will discuss resuming screening care.

        On the other hand, staffing a clinic that provided Pap screening, I have had patients referred after a diagnosis of end-stage cancer. I do not feel it is my place to tell these patients that the Pap is not indicated if the provider who referred them has not had the necessary conversation with them.

        One final thing: this is a problem with “check-box” medicine. Focusing on what the computer or some other external body says is necessary rather than looking at what the living, breathing human being who is the patient needs not only drives up costs unnecessarily but is poor patient care.

      • Sarah

        Thank you for your good advice and wishes for my health. I am truly touched by your kindness.

        My oncologist sent an email to my PCP about my situation, but I don’t know if he ever entered my prognosis in my EMR (shared by everyone in my HMO). You’d think this would be important information, but then, perhaps he would hesitate to document something that amounts to an educated guess. I will ask him about this.

        I don’t mean to sound churlish about my first PCP. He wants the best for me in his own way, and maybe because I still look young and healthy it is difficult to perceive me as someone who is ill. But, still, I’m glad to be on the same page with my new PCP and take advantage of bad-prognosis perks like skipping mammograms.

  • http://priorauthorizationtraining.blogspot.com/ Terri Richards, RN, BSN

    Great post! It is so important that we look at all means of controlling health care costs, including eliminating tests and procedures that do not benefit patients. Thanks!

  • Dr Chris

    The same applies not just to advanced cancer, but end stage lung disease. heart disease, advanced dementia, and so forth.
    If they wouldn’t survive the cure, the screening shouldn’t be done.

  • http://www.drjoe.net.au Dr Joe

    It is amazing how medicine has become so “cookie -cutter” in nature due to endless guidelines and protocols on “best practice”.