Comparing Prognostic Tools for Cancer Screening: Considerations for Clinical Practice and Performance Assessment

Variation in Receipt of Cancer Screening and Immunizations by 10-year Life Expectancy among U.S. Adults aged 65 or Older in 2019

IMPORTANCE

The likelihood of benefit from a preventive intervention in an older adult depends on its time-to-benefit and the adult's life expectancy. For example, the time-to-benefit from cancer screening is >10 years, so adults with <10-year life expectancy are unlikely to benefit.

OBJECTIVE

To examine receipt of screening for breast, prostate, or colorectal cancer and receipt of immunizations by 10-year life expectancy.

DESIGN

Analysis of 2019 National Health Interview Survey.

PARTICIPANTS

8,329 non-institutionalized adults >65 years seen by a healthcare professional in the past year, representing 46.9 million US adults.

MAIN MEASURES

Proportions of breast, prostate, and colorectal cancer screenings, and immunizations, were stratified by 10-year life expectancy, estimated using a validated mortality index. We used logistic regression to examine receipt of cancer screening and immunizations by life expectancy and sociodemographic factors.

KEY RESULTS

Overall, 54.7% of participants were female, 41.4% were >75 years, and 76.4% were non-Hispanic White. Overall, 71.5% reported being current with colorectal cancer screening, including 61.4% of those with <10-year life expectancy. Among women, 67.0% reported a screening mammogram in the past 2 years, including 42.8% with <10-year life expectancy. Among men, 56.8% reported prostate specific antigen screening in the past two years, including 48.3% with <10-year life expectancy. Reported receipt of immunizations varied from 72.0% for influenza, 68.8% for pneumococcus, 57.7% for tetanus, and 42.6% for shingles vaccination. Lower life expectancy was associated with decreased likelihood of cancer screening and shingles vaccination but with increased likelihood of pneumococcal vaccination.

CONCLUSIONS

Despite the long time-to-benefit from cancer screening, in 2019 many US adults age >65 with <10-year life expectancy reported undergoing cancer screening while many did not receive immunizations with a shorter time-to-benefit. Interventions to improve individualization of preventive care based on older adults' life expectancy may improve care of older adults.

Estimating life expectancy adjusted by self-rated health status in the United States: national health interview survey linked to the mortality

Background

Life expectancy is increasingly incorporated in evidence-based screening and treatment guidelines to facilitate patient-centered clinical decision-making. However, life expectancy estimates from standard life tables do not account for health status, an important prognostic factor for premature death. This study aims to address this research gap and develop life tables incorporating the health status of adults in the United States.

Methods

Data from the National Health Interview Survey (1986–2004) linked to mortality follow-up through to 2006 (age ≥ 40, n = 729,531) were used to develop life tables. The impact of self-rated health (excellent, very good, good, fair, poor) on survival was quantified in 5-year age groups, incorporating complex survey design and weights. Life expectancies were estimated by extrapolating the modeled survival probabilities.

Results

Life expectancies incorporating health status differed substantially from standard US life tables and by health status. Poor self-rated health more significantly affected the survival of younger compared to older individuals, resulting in substantial decreases in life expectancy. At age 40 years, hazards of dying for white men who reported poor vs. excellent health was 8.5 (95% CI: 7.0,10.3) times greater, resulting in a 23-year difference in life expectancy (poor vs. excellent: 22 vs. 45), while at age 80 years, the hazards ratio was 2.4 (95% CI: 2.1, 2.8) and life expectancy difference was 5 years (5 vs. 10). Relative to the US general population, life expectancies of adults (age < 65) with poor health were approximately 5–15 years shorter.

Conclusions

Considerable shortage in life expectancy due to poor self-rated health existed. The life table developed can be helpful by including a patient perspective on their health and be used in conjunction with other predictive models in clinical decision making, particularly for younger adults in poor health, for whom life tables including comorbid conditions are limited.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12332-0.

National profile of the growing population of older adults who access community health centers

BACKGROUND

Community health centers (CHCs) are federally funded safety-net clinics that provide care to low income and medically underserved persons. The proportion of CHC patients aged ≥65 doubled in the last ten years, yet little is known about this population. We aim to describe the demographic and clinical characteristics of the older adult CHC population.

DESIGN

Cross sectional analysis.

SETTING

The nationally representative 2014 Health Center Patient Survey.

PARTICIPANTS

CHC patients ≥55 years.

MEASURES

We used descriptive statistics to characterize older adults across demographic and clinical variables. To determine differences by age, we stratified into three groups (55-64, 65-74, 75+ years). We used t-tests and chi-squared to calculate p values and survey weights to make national estimates.

RESULTS

We included 1875 older adults ≥55 years, representing over 4.2 million people. Older adults were mostly aged 55-64 (60%), female (51%), and white (60%). The majority (73%) had Medicare or Medicaid and 47% reported fair or poor health. Regardless of age, older adults had an average of three chronic conditions and 0.6 impairments in activities of daily living (ADL). Healthcare utilization was not significantly different across age groups with most taking ≥5 prescription medications (54%) and one in five reporting ≥2 emergency department visits or ≥1 hospitalization in the last year.

CONCLUSIONS

Adults 55-64 who attend CHCs have similar disease burden as adults ≥65. As the population of older adults who access CHCs grow, our findings highlight the opportunity to enhance focus on key principles of geriatric medicine, such as measurement of functional impairment for those who are <65 while also addressing underlying health disparities.

Unrelated Death After Colorectal Cancer Screening: Implications for Improving Colonoscopy Referrals

The observed mortality < 5 years after the index colonoscopy lowered the overall impact of screening, which should prompt health care providers to perform a more thorough assessment of the potential reduced benefit for individual veterans when incorporating cancer risk, comorbidity burden, and age-based criteria.

Predicting 7-year mortality for use with evidence-based guidelines for Prostate-Specific Antigen (PSA) testing: findings from a large prospective study of 123 697 Australian men

OBJECTIVES

To develop and validate a prediction model for short-term mortality in Australian men aged ≥45years, using age and self-reported health variables, for use when implementing the Australian Clinical Practice Guidelines for Prostate-Specific Antigen (PSA) Testing and Early Management of Test-Detected Prostate Cancer. Implementation of one of the Guideline recommendations requires an estimate of 7-year mortality.

DESIGN

Prospective cohort study using questionnaire data linked to mortality data.

SETTING

Men aged ≥45years randomly sampled from the general population of New South Wales, Australia, participating in the 45 and Up Study.

PARTICIPANTS

123 697 men who completed the baseline postal questionnaire (distributed from 1 January 2006 to 31 December 2008) and gave informed consent for follow-up through linkage of their data to population health databases.

PRIMARY OUTCOME MEASURES

The primary outcome was all-cause mortality.

RESULTS

12 160 died during follow-up (median=5.9 years). Following age-adjustment, self-reported health was the strongest predictor of all-cause mortality (C-index: 0.827; 95% CI 0.824 to 0.831). Three prediction models for all-cause mortality were validated, with predictors: Model-1: age group and self-rated health; Model-2: variables common to the 45 and Up Study and the Australian Health Survey and subselected using stepwise regression and Model-3: all variables selected using stepwise regression. Final predictions calibrated well with observed all-cause mortality rates. The 90th percentile for the 7-year mortality risks ranged from 1.92% to 83.94% for ages 45-85 years.

CONCLUSIONS

We developed prediction scores for short-term mortality using age and self-reported health measures and validated the scores against national mortality rates. Along with age, simple measures such as self-rated health, which can be easily obtained without physical examination, were strong predictors of all-cause mortality in the 45 and Up Study. Seven-year mortality risk estimates from Model-3 suggest that the impact of the mortality risk prediction tool on men's decision making would be small in the recommended age (50-69 years) for PSA testing, but it may discourage testing at older ages.

The Medicare Annual Wellness Visit

The Medicare Annual Wellness Visit is an annual preventive health benefit, which was created in 2011 as part of the Patient Protection and Affordable Care Act. The visit provides an opportunity for clinicians to review preventive health recommendations and screen for geriatric syndromes. In this article, the authors review the requirements of the Annual Wellness Visit, discuss ways to use the Annual Wellness Visit to improve the care of geriatric patients, and provide suggestions for how to incorporate this benefit into a busy clinic.

Cancer Screening of Older Adults in Israel According to Life Expectancy: Cross Sectional Study

OBJECTIVES

To examine over-screening of older Israelis for colon and breast cancer.

DESIGN

Cross sectional.

SETTING

Clalit Health Services (CHS), Israel's largest health maintenance organization (HMO), provides care for more than half of the country's population and operates a national age-based programs for cancer screening.

PARTICIPANTS

All community-dwelling members aged 65 to 79 in 2014 (N = 370,876).

MEASUREMENTS

We used CHS data warehouse to evaluate cancer screening during 2014. Life expectancy (LE) was estimated using the validated Schonberg index.

RESULTS

Almost one-quarter (23.1%; 15.6% of adults aged 65-74, 42.7% of adults aged 75-79) of the study population had an estimated LE of less than 10 years. Annual fecal occult blood test and biannual mammography rates among adults aged 65 to 74 with a LE of 10 years or longer were 37.1% and 70.0%, respectively. Rates dropped after age 75 (4.0%, 19.5%) and to a lesser extent with a LE of less than 10 years (31.6%, 56.4%). Prostate-specific antigen testing is not part of the national screening program, and the proportion of people tested (42.6%), did not vary similarly with age of 75 and older (43.2%) or LE of less than 10 years (38.1%).

CONCLUSION

The cancer screening inclusion criteria of the national referral system have a strong effect on receipt of screening; LE considerations are less influential. Some method of estimating LE could be incorporated into algorithms to improve individualized cancer screening to reduce over- and underscreening of older adults.

Predicting Mortality up to 14 Years Among Community-Dwelling Adults Aged 65 and Older

OBJECTIVES

Extended validation of an index predicting mortality among community-dwelling US older adults.

DESIGN/SETTING

Examination of the performance of a previously developed index in predicting 10- and 14-year mortality among respondents to the 1997-2000 National Health Interview Surveys (NHIS) using the original development and validation cohorts. Follow-up mortality data are now available through 2011.

PARTICIPANTS

16,063 respondents from the original development cohort and 8,027 respondents from the original validation cohort. All participants were community dwelling and ≥65 years old.

MEASUREMENTS

We calculated risk scores for each respondent based on the presence or absence of 11 factors (function, illnesses, behaviors, demographics) that make up the index. Using the Kaplan Meier method, we computed 10- and 14-year mortality estimates for the development and validation cohorts to examine model calibration. We examined model discrimination using the c-index.

RESULTS

Participants in the development and validation cohorts were similar. Participants with risk scores 0-4 had 23% risk of 14-year mortality whereas respondents with risk scores (13+) had 89% risk of 14-year mortality. The c-index of the model in both cohorts was 0.73 for predicting 10-year mortality and 0.72 for predicting 14-year mortality. Overall, 18.4% of adults 65-74 years and 60.2% of adults ≥75 years have >50% risk of mortality in 10 years.

CONCLUSIONS

Our index demonstrated excellent calibration and discrimination in predicting 10- and 14-year mortality among community-dwelling US adults ≥65 years. Information on long-term prognosis is needed to help clinicians and older adults make more informed person-centered medical decisions and to help older adults plan for the future.