年長者的癌症篩檢率過高


  【24drs.com】根據康乃狄克大學Keith M. Bellizzi醫師等人的研究,許多75歲以上的年長者仍繼續定期篩檢大腸直腸癌、乳癌、子宮頸癌、前列腺癌,而指引並未建議此年齡層的人進行此類例行篩檢。作者們在12/26版內科醫學誌發表研究結果。
  
  Bellizzi醫師等人寫道,目前的美國預防服務工作小組篩檢指引建議,沒有足夠證據評估75歲以上成人進行篩檢對死亡率的效益,建議需依個人情況決定。但是,作者們發現篩檢率居高不下,顯然有關癌症篩檢的決策並未依循充分的知識,也未討論此類檢測的風險與利益。
  
  這篇研究中,Bellizzi醫師等人分析了「National Health Interview Survey」的資料,這是美國年度例行的全國家戶調查、共約30,000個家庭,用以追蹤美國的健康趨勢。研究者納入了1,697名年紀75-79歲與2,376名80歲以上者進行分析,這些樣本來自「National Health Interview Survey」的49,575名病患。
  
  研究結果顯示,75-79歲的婦女有62%、80歲以上婦女有50%在近兩年內有進行一次乳房攝影,而三年內有繼續進行定期巴氏檢測的年長婦女比率也是很高:75-79歲的婦女有53%、80歲以上婦女有38%。這篇研究中,不論男性女性,都進行了定期的大腸直腸篩檢,包括糞便潛血檢測、乙狀結腸鏡檢查或大腸鏡檢查。75-79歲者有57%、80歲以上者有47%表示接受過大腸直腸癌篩檢。使用傳統的前列腺特異抗原(PSA)檢測前列腺癌的比率也很高,過去一年內,75-79歲的男性進行過PSA檢查的比率有57%,80歲以後降至42%。
  
  篩檢的最明顯預測因子就是醫師建議進行特別檢查,超過50%的75歲以上男性和女性表示,他們的醫師建議進行例行性篩檢;另一個強烈預測因子是教育,雖然篩檢的盛行率依據種族而有所不同,校正教育這個變項之後,這些差異消失。作者指出,和75歲以上具大學程度者相比,低教育程度者(沒有高中文憑)顯然比較不會篩檢乳癌、子宮頸癌、大腸直腸癌、前列腺癌。
  
  這篇研究發現的高篩檢率值得考量,因為增加篩檢可能令這些共病症比較多的年長者進行侵犯性檢測,在經濟考量上,建議年長者進行例行性篩檢可能是不明智的。作者們寫道,在美國,估計目前65歲以上者的人數為3,680萬人,預估在2030年時會加倍。提供越來越多的年長者高品質的照護,同時還要控制成本,將會是重大挑戰。
  
  舊金山退伍軍人醫學中心、加州大學舊金山分校老年醫學組Louise C. Walter醫師在編輯評論中指出,隨著壽命增加,年長者可能從癌症篩檢獲益,而疾病發生率也隨著年紀增加;但是年長者也比較可能會因為侵犯性檢查的偽陽性結果而受到傷害。
  
  Walter醫師指出,很難知道這篇報告中的篩檢率是否過高,因為篩檢的風險與利益受到年紀之外的其他因素影響,例如病患的健康狀態與篩檢史。Walter醫師問道,Bellizzi醫師等人提出的問題為,品質測量是否可代表癌症篩檢的過度使用,目前,癌症篩檢的品質測量聚焦在75歲以下者的篩檢增加,但是,過度篩檢的問題為何?
  
  她指出,重點不是在於確認年長者「正確的」癌症篩檢比率,而是要評估這些年長者中,哪些類型的人顯然可以不需要接受這些檢查,例如曾因良性疾病進行全子宮切除術的婦女(即不需要接受巴氏檢測),或者,那些預估存活不會超過5年者。
  
  Walter醫師也建議,有關癌症篩檢的品質測量應提供的資料為,年長者在有關癌症篩檢的決策過程中是否有被醫師告知。雖然有關年長者癌症篩檢的「正確比率」依舊有所爭議,決策時的告知率務必要達到100%。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=6678&x_classno=0&x_chkdelpoint=Y
  

Overly High Rates of Cancer Screening Seen in Elderly Adults

By Barbara Boughton
Medscape Medical News

December 12, 2011 — Adults older than 75 years continue to have regular screenings for colorectal, breast, cervical, and prostate cancer despite guidelines that recommend against such routine screenings in this population, according to a study by Keith M. Bellizzi, MD, MPH, from the University of Connecticut, Storrs, and colleagues. The authors published their results in the December 12/26 issue of the Archives of Internal Medicine.

"Current US Preventive Services Task Force...screening guidelines suggest that there is insufficient evidence to evaluate the mortality benefits of screening men and women older than 75 years and advocate for individualized decisions in this group," Dr. Bellizzi and fellow researchers write. Yet the elevated screening rates the authors found suggest that decisions regarding cancer screening are being made without full knowledge or discussion of the risks and benefits of such tests.

In the study, Dr. Bellizzi and colleagues analyzed data available from the National Health Interview Survey, an annual in-person nationwide survey of about 30,000 households that is used to track health trends in the United States. The researchers included 1697 adults aged 75 to 79 years and 2376 adults older than 80 years in their analysis, derived from a sample of 49,575 patients in the National Health Interview Survey.

Their results showed that 62% of women aged 75 to 79 years and 50% of women aged 80 years and older reported getting a mammogram within the last 2 years. A high percentage of older women also continued to receive regular Papanicolaou tests within the last 3 years: 53% among those women aged 75 to 79 years and 38% among women older than 80 years reported these screenings. Older men and women in the study both reported regular colorectal screenings, including fecal occult blood tests, sigmoidoscopy, or colonoscopy. Fifty-seven percent of those aged 75 to 79 years, and 47% of those older than 80 years, reported undergoing colorectal cancer screenings. Screening rates for prostate cancer using the controversial prostate-specific antigen (PSA) test were also high. The prevalence of a PSA test within the past year was highest among men aged 75 to 79 years (57%), decreasing to 42% after age 80 years.

The most significant predictor for screening was physician recommendation for a particular test. More than 50% of men and women who were older than age 75 years recalled that their physician recommended regular screening. Another strong predictor of screening was education. Although prevalence rates for screening differed by race and ethnicity, these differences disappeared when the authors adjusted for education. Those with low education (without a high school diploma) were significantly less likely to be screened for breast, cervical, colorectal, and prostate cancer when compared with adults older than age 75 years who had a college degree, according to the authors.

The high screening rates found in the study are a concern because increased screenings may subject older adults—who have more comorbidities than younger—to invasive tests. Recommending regular screenings for older adults may also be unwise from an economic standpoint. "In the United States, the number of adults 65 years of older, currently estimated at 36.8 million, is expected to double by the year 2030. Providing high-quality care to this growing population while attempting to contain costs will pose a significant challenge," the authors write.

With increased longevity, older adults can potentially benefit from cancer screening tests, as the incidence of the disease increases with age, noted Louise C. Walter, MD, from the Division of Geriatrics, University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, in an accompanying editorial. Yet older adults are also subject to more harm from invasive procedures after false-positive results from cancer screenings, she notes.

Dr. Walter points out that it's difficult to know whether the screening rates reported in this study are too high, as the risks and benefits of screening are influenced by many patient factors other than age, such as the patient's health status and history of screening. "Still the data by Bellizzi et al raise the issue of whether quality measures should address the overuse of cancer screening. Currently, quality measures in cancer screening focus on increasing screening in persons younger than age 75 years, but what about the problem of overscreening?" Dr. Walter asks.

Rather than focusing on determining the "right" cancer screening rate among adults in older age groups, it would be more useful to assess cancer screening rates among subgroups of older adults who clearly should not receive these tests, such as women who have had a total hysterectomy for benign disease (and thus should not receive Papanicolaou tests) and those with life-limiting illness who are not expected to survive past 5 years, she notes.

Dr. Walter also suggests that future quality measures regarding cancer screenings should provide data on whether older adults engage in an informed decision-making process about cancer screenings with their physician. "While arguments persist about what is the 'right' rate of cancer screening in older persons, it seems clear that the rate of informed decision-making should approach 100%," she writes.

Dr. Bellizzi reported receiving compensation from the National Cancer Institute for the study. Dr. Walter has disclosed no relevant financial relationships.

Arch Intern Med. 2011;171:2031-2038.

    
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