Prevention of Cancer in the Older Person

Screening for cancer: when to stop?: A practical guide and review of the evidence

Deciding when to stop cancer screening in older adults is a complex challenge that involves multiple factors: individual health status and life expectancy; risks and benefits of screening, which vary with age and comorbidity; and individual preferences and values. This article examines current cancer screening practices and reviews the risks and benefits of cancer screening for colorectal, breast, lung, prostate, and cervical cancer, particularly in older individuals and those with multiple comorbidities. Tools for estimating life expectancy are reviewed, and a practical framework is presented to guide discussions on when the harms of screening likely outweigh the benefits.

Extended long-term (> 5 years) outcome of cerebrospinal fluid shunting in idiopathic normal pressure hydrocephalus

BACKGROUND

Shunt surgery has been established as the only durable and effective treatment for idiopathic normal pressure hydrocephalus.

OBJECTIVE

We evaluated the "extended" long-term follow-up (> 5 years) in a prospective study cohort who underwent shunting between 1990 and 1995. A secondary objective was to determine the cause of death in these patients.

METHODS

Fifty-one patients were included after confirmation of the diagnosis by extensive clinical and diagnostic investigations. Surgery included ventriculoatrial or ventriculoperitoneal shunting with differential pressure valves in the majority of patients. For each of the cardinal symptoms, postoperative outcome was assessed separately with the Krauss Improvement Index, yielding a value between 0 (no benefit) and 1 (optimal benefit) for the overall outcome.

RESULTS

Mean age at surgery was 70.2 years (range, 50-87 years). Thirty patients were women, and 21 were men. Short-term (18.8 +/- 16.6 months) follow-up was available for 50 patients. The Krauss Improvement Index was 0.66 +/- 0.28. Long-term (80.9 +/- 51.6 months) follow-up was available for 34 patients. The Krauss Improvement Index was 0.64 +/-0.33. Twenty-nine patients died during the long-term follow-up at a mean age of 75.8 years (range, 55-95 years). The major causes of death were cardiovascular disorders: cardiac failure (n = 7) and cerebral ischemia (n = 12). Other causes were pneumonia (n = 2), acute respiratory distress syndrome (n = 1), pulmonary embolism (n = 1), cancer (n = 2), renal failure (n = 1), and unknown (n = 3). There was no shunt-related mortality.

CONCLUSION

Idiopathic normal pressure hydrocephalus patients may benefit from shunting over the long term when rigorous selection criteria are applied. Shunt-related mortality is negligible. The main cause of death is vascular comorbidity.

Changes in the risk of death from cancer up to five years after diagnosis in elderly patients: a study of five common cancers

Cancer mortality in elderly people is described to highlight the mechanisms that could potentially explain observed differences with other age groups. Data from 15 French cancer registries were considered in the search for the 5-year outcome of patients diagnosed during the period 1989-1997. Relative survival, excess mortality hazard, and hazard ratio of mortality were estimated to describe patient outcome according to age. Five cancer sites were selected: colon/rectum, prostate, breast, head/neck, and lung. An excess mortality rate was found in patients aged over 75 at the time of diagnosis. This excess mortality rate was mainly seen during the first months after diagnosis, then it decreased gradually with time. An initial phenomenon of patient selection, a greater disease severity at the time of diagnosis, and less-effective treatments given to elderly patients are the most plausible explanations for the increased risk of cancer-related death in the eldest patients.

Diagnosing and Treating Breast Cancer in Elderly Women: A Call for Improved Understanding

Breast cancer is the most common nondermatological malignancy in women, and the incidence increases with age until the eighth decade. Breast cancer pathology and biology appear to be different in elderly patients than in younger ones, and therefore treatment recommendations cannot be generalized from one group to the other. Most elderly women can tolerate breast cancer surgery without significant complications and should be offered a definitive surgical procedure. Improved mechanisms to predict which patients will tolerate and benefit from various therapies are under development. Because most breast cancers in the elderly are hormone responsive, hormonal therapy remains the mainstay of systemic treatment in the adjuvant and metastatic settings. Chemotherapy can be used in elderly women, but treatment decisions must be individualized based upon risk-benefit analyses. Elder-specific studies are underway to identify the most-efficacious and best-tolerated therapies for breast cancer in this population. Primary care physicians must be aware of these issues to provide adequate counseling and care to these patients.

Disability and receipt of clinical preventive services among women

BACKGROUND

More individuals are surviving catastrophic injuries and living longer with persistent disability; however, their receipt of clinical preventive services is not well understood as compared with those without disabilities given the dual focus of care on both primary prevention and the prevention of secondary complications related to their disabilities.

METHODS

Longitudinal analyses of 1999-2002 Medical Expenditure Survey (MEPS). Study sample consisted of 3,183 community-dwelling women aged 51-64 years and followed for 2 full years. Women with disabilities were defined as having reported any limitation in any area of activity of daily living in 2 years. Recommended clinical preventive services were defined as receiving the following at the recommended intervals: colorectal, cervical, and breast cancer; cholesterol screening; and influenza immunization. chi(2) tests and multiple logistic regressions were used to examine variations in use of clinical preventive services.

RESULTS

Overall, 23% of the women in the study (n = 835) were disabled. Disabled women, however, were less likely to receive mammography and Pap smears within the recommended intervals. However, disabled women were more likely to receive influenza immunization, cholesterol screening, and colorectal screening within the recommended intervals. Among the disabled, usual source of care and health insurance remained significant predictors of receipt of clinical preventive services across all types,

CONCLUSIONS

Disabled women were less likely to receive some of the cancer screening services, suggesting a need for targeted interventions to promote breast cancer and cervical cancer screening. Increased access to health care insurance and health care providers may also help.