SECG Blog

The challenges of addressing overdiagnosis and overtreatment in older people (4 min read)

 

Ms Jenna Smith
PhD Candidate & Research Assistant
Sydney Health Literacy Lab & Wiser Healthcare
Sydney School of Public Health
The University of Sydney

Overdiagnosis and overtreatment are not straightforward concepts. When I first started my PhD, I found that I came up with multiple iterations of responses to the question, “So, what is your PhD on?” My succinct version was, “Supporting older adults to make informed cancer screening decisions.” This would often come with the response, “Oh, as in, to get older people to screen more?”

In the context of cancer, overdiagnosis is an important but under-recognised downside of screening. Overdiagnosis is when a person is diagnosed with a “harmless” cancer that either never grows or grows very slowly. This downside of cancer screening is relevant for younger people to also be informed about. But for older people (especially those with limited life expectancy and other health issues), the chance of experiencing the downside of screening becomes greater than the chance of experiencing benefit (1). This is because cancers detected through screening for older people have less chance of causing symptoms or problems in their remaining lifetime. However, it is impossible for doctors to tell which cancers will be harmless, so treatment is often recommended. Using the example of breast screening, some studies suggest it takes ten years (on average) to reap any benefit from cancer screening (i.e., reducing the chance of being harmed or dying from breast cancer) (2). However, evidence that quantifies the benefits and harms of breast screening in older women (≥70 years) is mixed, and the population-based evidence is difficult to apply to one particular individual.

Considering the uncertainty around the benefit of cancer screening for older people and the increased chance of harm, the best strategy for communication is to support an informed decision. For prostate cancer screening using the prostate-specific antigen (PSA) test, guidelines recommend that general practitioners (GPs) inform men aged ≥70 years who wish to screen that the downsides (diagnosing and treating a harmless cancer) may outweigh the benefits (3). However, it is difficult for health professionals to communicate about the option of stopping or not getting screening, incorporating sensitive topics such as life expectancy, and trying to explain the potential for limited benefit and potential harm from screening in older age (4, 5). Furthermore, patients have their own underlying beliefs and attitudes about screening and their risk of developing cancer that may run counter to guideline recommendations (6). For the longest time we have heard messaging persuading us to be screened, so why would there possibly be any downsides to consider?

Another layer of complexity when communicating about overdiagnosis to older people is the extremely pertinent and pervasive ageism in healthcare. An investigation of recent experiences of age discrimination by older adults accessing health care, “What can you expect at your age?!”, was published by the Older Women’s Network NSW and Health Consumers NSW in 2021. In the healthcare system, older adults experience ageism when they are told or made to believe that they are ‘too old’ for a certain healthcare intervention, or a ‘waste of resources’. Preliminary findings from my qualitative interview research with older adults highlight that this was a prime reason for which they felt they were no longer reminded to get breast screening anymore, and GPs struggled with this conversation (5). For me, this highlighted the importance of providing more nuanced information around the changing benefit/harm trade-off of cancer screening, to ensure that older adults do not feel given up on and that they are enabled to make an informed choice. It is not okay to communicate (either directly or indirectly) to older people that they no longer need a healthcare intervention because they are “too old”.

It is impossible for me, a 27-year-old, white, cisgender female to understand how frustrating and hurtful such experiences of being negatively stereotyped and therefore excluded from accessing health services can be. However, my research, together with these reports on ageism in healthcare, highlight how much work we have to do to ensure sensitive, clear, and evidence-based communication and information is provided to older people regarding their healthcare. There are situations in which an older person may no longer benefit from certain interventions. However, communicating this information and advice must be met with kindness, care and patience, and certainly without age discrimination. Not only is it essential that older people are not left behind and miss out on appropriate and deserved care, but that they also avoid unnecessary healthcare that has a genuine danger of causing more harm than benefit.

25 August 2022

 

References:

  1. Kotwal, A.A., Walter, L.C. Cancer Screening Among Older Adults: a Geriatrician’s Perspective on Breast, Cervical, Colon, Prostate, and Lung Cancer Screening. Curr Oncol Rep 22, 108 (2020). https://doi.org/10.1007/s11912-020-00968-x
  2. Walter LC, Schonberg MA. Screening Mammography in Older Women: A Review. JAMA. 2014;311(13):1336–1347. doi:10.1001/jama.2014.2834
  3. Prostate Cancer Foundation of Australia and CancerCouncil Australia. Draft clinical practice guidelines for PSA testing and early management of test-detected prostate cancer. Prostate Cancer Foundation of Australia and Cancer Council Australia PSA Testing Guidelines Expert Advisory Panel. 2016. https://www.pcfa.org.au/media/611412/PSA-Testing-Guidelines-Overview.pdf
  4. Schoenborn N.L., Boyd C.M., Lee S.J., Cayea D., & Pollack C.E. Communicating About Stopping Cancer Screening: Comparing Clinicians’ and Older Adults’ Perspectives, The Gerontologist, Volume 59, Issue Supplement_1, June 2019, Pages S67–S76, https://doi.org/10.1093/geront/gny172
  5. Smith J., Dodd R.J., Wallis, K., Naganathan, V., Cvejic, E., Jansen, J. & McCaffery, K.J. General practitioners’ views and experiences of communicating with older people about cancer screening: A qualitative study. 2022 (Under Review)
  6. Smith J., Dodd R.H., Gainey K.M., et al. Patient-Reported Factors Associated With Older Adults’ Cancer Screening Decision-making: A Systematic Review. JAMA Network Open. 2021;4(11):e2133406. doi:10.1001/jamanetworkopen.2021.33406
  7. Older Women’s Network NSW & Health Consumers NSW. “What can you expect at your age?!” An investigation of recent experiences of age discrimination by older adults accessing health care. Older Women’s Network NSW & Health Consumers NSW. 2021. https://www.hcnsw.org.au/wp-content/uploads/2021/03/Ageism-in-Health-Care_final.pdf
 

image source: https://www.medicalrepublic.com.au/fight-continues-looming-threeat-overdiagnosis/17472

Jenna is a PhD candidate in the Sydney School of Public Health, University of Sydney.

She completed her Honours in Psychology in the Lab in 2018 under the supervision of Associate Professor Jesse Jansen, with a particular interest in cancer screening in older adults. Jenna commenced her PhD in March 2020 to continue her studies in this area under the supervision of Professor Kirsten McCaffery, Associate Professor Jesse Jansen, Dr Rachael Dodd, Dr Erin Cvejic, and Professor Vasi Naganathan.

This mixed methods program of research aims to understand how older adults and their doctors make decisions about cancer screening in Australia. It will provide the groundwork of evidence needed to ensure older people are supported to make an informed choice about cancer screening.

Jenna was one of the 2021 RM Gibson Program recipients to fund a survey investigating older adults' cancer screening decision-making.