Using Prognosis to Make Screening Decisions

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

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

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

14. 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

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

16. 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

17. 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

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

19. Mr. A

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