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Using Prognosis to Make Screening Decisions

This presentation discusses potential screening measures for older adults and the role of life expectancy in deciding when to stop or continue screening. It also identifies and utilizes useful prognostic tools for making screening decisions.

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Using Prognosis to Make Screening Decisions

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  1. Using Prognosis to Make Screening Decisions Elizabeth Eckstrom, MD, MPH Oregon Health & Science University Hollis Day, MD, MS University of Pittsburgh

  2. 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

  3. 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

  4. 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

  5. Life Expectancy Curves

  6. Life Expectancy Curves Mrs. Smith is 70 and healthy, when she develops breast cancer, with a 5 year mortality rate of 25% (this is a later stage breast cancer) Finding and curing her breast cancer could add 7 years of life

  7. 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?

  8. Study of Prognosis: 11,000 participants asked questions about diseases and functional status, followed over 4 yearsValidated with a second group of subjects-Lee, JAMA, 2006

  9. Mr. Jones84 years oldHas diabetesSmokes 1 ppdCan walk ½ mileWhat is his prognosis?

  10. Mr. Jones84 years oldHas diabetesSmokes 1 ppdCan only walk one block What is his prognosis?

  11. 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

  12. Remaining Life Expectancy Women Men Walter LC, JAMA, 2001

  13. 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

  14. 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

  15. Mr. A 75 y/o man with CHF, smokes, and has difficulty bathing, walking, and managing finances.

  16. Mr. A

  17. USPSTF Changes Affecting Your Practice • New guidelines with geriatric component • Consideration of how recommendations affect elderly patients

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