Living

Silver lining of old age: Ditching the screenings

FOTOLIAAfter a certain age, it may not pay to undergo a number of health screenings.
FOTOLIAAfter a certain age, it may not pay to undergo a number of health screenings. TNS

Feeling sorry for yourself because you can no longer do all the things you used to do? Because your joints are creaky and your strength and stamina seem to be dribbling out along with your memory?

Take heart in the fact that growing old comes with a silver lining of sorts.

You can cross a bunch of things off your health-related to-do list, including routine screening tests for cancer and other health issues.

According to the U.S. Preventive Services Task Force, average-risk folks can stop getting mammograms for breast cancer and colonoscopies for colon cancer around 75.

And, after 65, most women can forget about Pap tests for cervical cancer.

The task force does not recommend prostate cancer screening for men of any age, but the American Urological Association, which suggests that men over 55 discuss screening with their doctors, sets an age limit of 69.

While some people may find this liberating, however, others are troubled by it.

"Some people are so indoctrinated about screening -- we're taught that's what socially responsible people do -- that it can be hard to give up," said Dr. Lisa Schwartz of the Dartmouth Institute for Health Policy and Clinical Practice

in Lebanon, N.H.

The chance of being diagnosed with cancer goes up as you age, but competing risks, such as heart attacks and strokes, are increasing faster.

"So you don't have to worry so much about (cancer) screening because you're more likely to die of something else," said her husband and colleague, Dr. Steven Woloshin. "That's a hard conversation for doctors and patients to have."

Schwartz and Woloshin, professors of medicine at the Dartmouth Institute, have written extensively about communicating medical risk.

Balancing benefit, harm

Telling a patient she doesn't have enough time left to reap the potential benefit of a screening test isn't always perceived as good news. The related message, that a competing risk is more likely to get her, likewise might be hard to swallow. So Schwartz and Woloshin might instead talk about the balance of benefits and harms.

The harms of cancer screening, including complications of a biopsy and side effects of treatment if cancer is found, are "front-loaded," Woloshin said. The potential benefit -- preventing death from the disease -- can be elusive, especially if the cancer is growing slowly.

Dr. Ranit Mishori, professor of family medicine at Georgetown University in Washington, notes that the upper age limits on screening tests are "population-based." She prefers to have a discussion with each patient based on individual wishes and health status.

"When the patient is frail or has other serious illnesses, it makes sense not to screen for diabetes or breast or colon cancer," she said. "But if you have a robust, active 75-year-old who plays tennis and you think they have another 10, 15, even 20 years ahead of them, the question of whether they should be screened becomes different."

She also takes into account the nature of the test. Climbing onto an exam table for a Pap test might be hard for a patient with mobility issues. The benefit of the test is unlikely to outweigh the discomfort.

But even cholesterol screening, which involves only a blood draw, is probably unnecessary after a certain age. "At 70 or 80, will the benefit of the test be such that you want the patient to have to take a pill every day and potentially suffer its side effects?" she asked, noting that older patients are more sensitive to medications and more likely to suffer ill effects.

There are no age limits on blood pressure screening. And taking someone's blood pressure is quick and noninvasive. "Everybody gets a blood pressure reading," Mishori said, "and if it's high, we have a conversation. Do you want to be treated? If you're 50, it could make a huge difference. If you're 85, the ramifications are different. We can be more permissive in older individuals in terms of blood pressure and blood sugar limits."

When a patient is outside the recommended age range for a screening test, Mishori said, "we have a conversation about risks and benefits. More often than not, the patients opt not to screen. But occasionally someone wants to have a few more years of tests."

Dr. Nortin Hadler, emeritus professor of medicine at the University of North Carolina at Chapel Hill and author of "Rethinking Aging," sees even less value in screening tests.

"Everybody knows their numbers," he said. "They take their blood pressure, cholesterol, BMI (body mass index), A1C (blood sugar). All these numbers speak to an element of risk for something. We need to ask: How much risk? And what's the something? Will reducing that particular risk matter in the overall scheme?"

A Pap test indicates the risk of developing cervical cancer. But, Hadler said, "we won't do anything meaningful with a Pap smear in an older woman -- it won't change the date you die."

On the subject of high blood pressure, he said: "It will increase the likelihood of heart attack and stroke, but by how much? And is it a function of something else, like my age? The answer is yes -- age is a bigger risk factor. The older you are, the sooner you will die."

Gentler drug option

Hadler conceded that he would "rather not have a stroke in the last years of my life, and I can reduce that risk a little bit if I normalize my blood pressure." For most of the elderly, he said, that little bit can be accomplished with the gentlest of drugs -- often just a low-dose water pill -- whereas "getting it truly normal through aggressive means could make you sicker, because all drugs have side effects."

As to cholesterol, Hadler said, "treating high cholesterol in older well people (that is, people who have not already had a heart attack or stroke) is unconscionable," because the potential benefit does not outweigh the risk of serious adverse events.

And if you're not going to treat it, there is no reason to test for it.

The same goes for screening for Type 2 diabetes, the kind that develops later in life. According to Hadler, oral drugs that lower blood sugar, though popular, have never been shown to improve longevity; decrease the incidence of stroke, heart attack or loss of limbs; or prevent kidney failure or blindness. But they are associated with occasionally serious adverse events.

The task force recommends screening for Type 2 diabetes only in people with high blood pressure. But it's because hypertension is more dangerous in diabetics, Hadler said; "it's not to treat the diabetes."

Here's one more thing you can stop worrying about: your BMI. Being overweight or even moderately obese will not take time off your allotted lifespan, Hadler said (although being underweight or morbidly obese will).

And those extra 10 pounds might plump out some of your wrinkles.

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