Using Prognosis to Make Screening Decisions Elizabeth Eckstrom, MD, MPH Oregon Health & Science University Hollis Day, MD, MS University of Pittsburgh

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

Prevention- wow, thats 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

When should you stop screening older adults? When considering screening, think about the patients 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

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

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?

Study of Prognosis: 11,000 participants asked questions about diseases and functional status, followed over 4 years Validated with a second group of subjects -Lee, JAMA, 2006

Mr. Jones 84 years old Has diabetes Smokes 1 ppd Can walk ½ mile What is his prognosis?

Mr. Jones 84 years old Has diabetes Smokes 1 ppd Can only walk one block What is his prognosis?

How does this translate back to life expectancy for screening? It doesnt 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

Remaining Life Expectancy Women Men Walter LC, JAMA, 2001

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

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

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

Mr. A

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