Cancer screening and aging: Research barriers and opportunities

Should we screen for colorectal cancer in people aged 75 and over? A systematic review - collaborative work of the French geriatric oncology society (SOFOG) and the French federation of digestive oncology (FFCD)

BACKGROUND

We have done a systematic literature review about CRC Screening over 75 years old in order to update knowledge and make recommendations.

METHODS

PUBMED database was searched in October 2021 for articles published on CRC screening in the elderly, and generated 249 articles. Further searches were made to find articles on the acceptability, efficacy, and harms of screening in this population, together with the state of international guidelines.

RESULTS

Most benefit-risk data on CRC screening in the over 75 s derived from simulation studies. Most guidelines recommend stopping cancer screening at the age of 75. In private health systems, extension of screening up to 80-85 years is, based on the life expectancy and the history of screening. Screening remains effective in populations without comorbidity given their better life-expectancy. Serious adverse events of colonoscopy increase with age and can outweigh the benefit of screening. The great majority of reviews concluded that screening between 75 and 85 years must be decided case by case.

CONCLUSION

The current literature does not allow Evidence-Based Medicine propositions for mass screening above 75 years old. As some subjects over 75 years may benefit from CRC screening, we discussed ways to introduce CRC screening in France in the 75-80 age group. IRB: An institutional review board composed of members of the 2 learned societies (SOFOG and FFCD) defined the issues of interest, followed the evolution of the work and reviewed and validated the report.

A Motivational Interviewing Intervention to Promote CRC Screening: A Pilot Study

BACKGROUND

Appalachian Kentuckians suffer a disproportionate incidence and mortality from colorectal cancer (CRC) and are screened at lower rates (35%) compared with 47% of Kentuckians.

OBJECTIVE

The aim of this study was to evaluate the efficacy of a motivational interviewing intervention delivered by trained Lay Health Advisors on CRC screening.

METHOD

Eligible participants recruited from an emergency department (ED) completed a baseline survey and were randomized to either the control or the motivational interviewing intervention provided by Lay Health Advisors. Follow-up surveys were administered 3 and 6 months after baseline. To evaluate potential differences in treatment and control groups, t tests, χ, and Mann-Whitney U tests were used.

RESULTS

At either the 3- or 6-month assessment, there was no difference in the CRC screening by group (χ = 0.13, P = .72). There was a significant main effect for the study group in the susceptibility to CRC model; regardless of time, those in the intervention group reported approximately 1-point higher perceived susceptibility to CRC, compared with controls (est. b = 0.68, P = .038). Age and financial adequacy had a significant effect related to CRC screening. Older participants (est. b = 0.09, P = .014) and those who reported financial inadequacy (est. b = 2.34, P = .002) reported more screening barriers.

CONCLUSION

This pilot study elucidated important factors influencing the uptake of CRC for an ED transient population and this may be useful in the design of future interventions using motivational interviewing in EDs.

IMPLICATIONS FOR PRACTICE

Nurses can provide information about CRC screening guidelines and provide referrals to appropriate screening resources in the community.

Transient elastography for screening of liver fibrosis: Cost-effectiveness analysis from six prospective cohorts in Europe and Asia

BACKGROUND & AIMS

Non-alcoholic fatty liver disease and alcohol-related liver disease pose an important challenge to current clinical healthcare pathways because of the large number of at-risk patients. Therefore, we aimed to explore the cost-effectiveness of transient elastography (TE) as a screening method to detect liver fibrosis in a primary care pathway.

METHODS

Cost-effectiveness analysis was performed using real-life individual patient data from 6 independent prospective cohorts (5 from Europe and 1 from Asia). A diagnostic algorithm with conditional inference trees was developed to explore the relationships between liver stiffness, socio-demographics, comorbidities, and hepatic fibrosis, the latter assessed by fibrosis scores (FIB-4, NFS) and liver biopsies in a subset of 352 patients. We compared the incremental cost-effectiveness of a screening strategy against standard of care alongside the numbers needed to screen to diagnose a patient with fibrosis stage ≥F2.

RESULTS

The data set encompassed 6,295 participants (mean age 55 ± 12 years, BMI 27 ± 5 kg/m², liver stiffness 5.6 ± 5.0 kPa). A 9.1 kPa TE cut-off provided the best accuracy for the diagnosis of significant fibrosis (≥F2) in general population settings, whereas a threshold of 9.5 kPa was optimal for populations at-risk of alcohol-related liver disease. TE with the proposed cut-offs outperformed fibrosis scores in terms of accuracy. Screening with TE was cost-effective with mean incremental cost-effectiveness ratios ranging from 2,570 €/QALY (95% CI 2,456-2,683) for a population at-risk of alcohol-related liver disease (age ≥45 years) to 6,217 €/QALY (95% CI 5,832-6,601) in the general population. Overall, there was a 12% chance of TE screening being cost saving across countries and populations.

CONCLUSIONS

Screening for liver fibrosis with TE in primary care is a cost-effective intervention for European and Asian populations and may even be cost saving.

LAY SUMMARY

The lack of optimized public health screening strategies for the detection of liver fibrosis in adults without known liver disease presents a major healthcare challenge. Analyses from 6 independent international cohorts, with transient elastography measurements, show that a community-based risk-stratification strategy for alcohol-related and non-alcoholic fatty liver diseases is cost-effective and potentially cost saving for our healthcare systems, as it leads to earlier identification of patients.

Impact of age on end-of-life care for adult Taiwanese cancer decedents, 2001-2006

BACKGROUND

With increasing patient age in Western countries, evidence indicates a pervasive pattern of decreasing healthcare expenditures and less aggressive medical care, including end-of-life (EOL) care. However, the impact of age on EOL care for Asian cancer patients has not been investigated.

PURPOSE

To explore how healthcare use at EOL varies by age among adult Taiwanese cancer patients.

METHODS

Retrospective cohort study using administrative data among 203,743 Taiwanese cancer decedents, 2001-2006. Age was categorized as 18-64, 65-74, 75-84, and ≥85 years.

RESULTS

Elderly (≥65 years) Taiwanese cancer patients were significantly less likely than those 18-64 years to receive aggressive treatment in their last month of life, including chemotherapy, >1 emergency room visits, >1 hospital admissions, >14 days of hospitalization, hospital death, intensive care unit admission, cardiopulmonary resuscitation, intubation, and mechanical ventilation. However, they were significantly more likely to receive hospice care in their last year of life.

CONCLUSION

Elderly Taiwanese cancer patients at EOL received less chemotherapy, less aggressive management of health crises associated with the dying process, and fewer life-extending treatments, but they were more likely to receive hospice care in their last year and to achieve the culturally highly valued goal of dying at home.

The human papillomavirus (HPV) vaccine and cervical cancer: uptake and next steps

Infection with a high-risk type of the human papillomavirus (HPV) is a major contributing factor in the vast majority of cervical cancers. Dissemination of the HPV vaccine is critical in reducing the risk of the disease. This descriptive review of HPV vaccine uptake in papers published between 2006 and 2011 focuses on studies conducted in girls and young women. In the United States, rates of immunization as per the protocol for teens (age 13-17 years) range from 6% to 75% and those for young women (age 18-26 years) range from 4% to 79%, although the samples and data collection methods vary. The epidemiology of HPV, the mechanisms of action, protocols for vaccine immunization, rates of uptake, and barriers to vaccination at the policy, provider, and patient levels are reviewed. Various intervention techniques are described, and policy-level programs, such as legislation supporting mandates, subsidized public education, and cost-reduction initiatives, are also explored. Increased distribution of the HPV vaccine in school-based clinics, evidencebased scripts for provider counseling of young patients and their parents, concurrent immunizations to adolescents, prevention visits, greater patient education and outreach, and the dissemination of academic detailing can help to boost vaccine uptake, particularly in underresourced communities. Population-based surveillance is necessary for robust estimates of uptake over time. Additional research is needed to comprehensively examine socio-demographic, psychosocial, and sociocultural factors that predict vaccine uptake according to the protocol. Increased study of the vaccine's long-term effectiveness, in both males and females and among extended age groups, is warranted.

Theory, measurement, and controversy in positive psychology, health psychology, and cancer: basics and next steps

The aims of this commentary are two-fold: First, to amplify some of the points that Aspinwall, Tedeschi, Coyne, Tennen, and Ranchor have raised, noting the importance of a return to basics. Second, to posit next steps in theory development and methods at the intersection of health psychology, positive psychology, and cancer. Additional theory development, more applications of large prospective studies, and instrument refinements are warranted to understand the effects of positive constructs on health outcomes and adaptation to cancer. This area of research would be strengthened by studies that incorporate survival, health-related quality of life, and well-being outcome measures, using cancer registries and/or multiple raters. More observational studies are necessary. Attention to social justice questions is suggested in future studies at the intersection of these fields.

Uptake of colorectal cancer screening: system, provider and individual factors and strategies to improve participation

Colorectal cancer (CRC) accounts for 9% of all new cancer cases worldwide and affects over 1 million people each year. Screening can reduce the mortality associated with the disease, yet participation rates are suboptimal. Compliers with CRC screening are less deprived; they have higher education than noncompliers and tend to be male, white and married. Likely reasons for nonparticipation encompass several 'modifiable' factors that could be targeted in interventions aimed at increasing participation rates. Successful intervention strategies include organizational changes, such as increasing access to fecal occult blood test (FOBT) kits, providing reminders to healthcare providers or users about screening opportunities, and educational strategies to improve awareness and attitudes towards CRC screening. Multifactor interventions that target more than one level of the screening process are likely to have larger effects. The biggest challenge for future research will be to reduce inequalities related to socio-economic position and ethnicity in the uptake of screening.

[Visceral and thoracic surgical interventions in patients over 80 years old. Evaluation of cost coverage]

Due to the higher incidence of malignant tumours with increasing age, cancer is the second most common cause of death among those aged over 65 years old. Consequently, demographic changes in Germany have resulted in a rising demand for oncological operations in elderly patients which is more cost-intensive. Objective of the present study in the setting of a university surgical department is whether oncological operations on patients over 80 years old is cost-effective in the era of diagnosis-related groups. The revenue and expenditure of 116 cases of patients over 80 years old documented for the years 2005-2007 were collated and evaluated. The calculated average proceeds were compared with cases of patients under 80 years old.The average return was -1493.50 EUR/case for over 80-year olds and was not cost-effective. The presence or absence of complications had a significant impact on proceeds, because the mean return/case without complications was profitable (1297.30 EUR). Medical care of patients over 80 years old was on average cost-effective and generated a profit. Oncological operations in patients under 80 years old were not sufficiently remunerated by the current DRG system. Therefore, there is an economical risk associated with oncological operations in elderly patients.