Cancer screening in elderly patients - A framework for individualized decision making
Cancer screening in elderly patients - A framework for individualized decision making
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DOI：
10.1001/jama.285.21.2750
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发表时间：
2001-06-06
影响因子：
120.7
通讯作者：
Covinsky, KE
中科院分区：
文献类型：
--
作者：
Walter, LC;Covinsky, KE
在老年人中使用癌症筛查试验存在相当大的不确定性，各指南小组推荐的不同年龄界限说明了这一点。我们建议，一个指导老年患者个性化癌症筛查决策的框架可能比年龄指南对执业临床医生更有用。像许多医疗决策一样，癌症筛查决策需要权衡定量信息，如癌症死亡风险和有益和不良筛查结果的可能性，以及定性因素，如个体患者的价值观和偏好。我们的框架首先通过对预期寿命、癌症死亡风险和基于公开数据的筛查结果的定量估计来锚定决策。筛查的潜在好处是，根据患者接受筛查期间的预期寿命，预防1例癌症特异性死亡所需的筛查数量。估计结果显示，年龄相近、预期寿命不同的患者获益的可能性存在很大差异。事实上，预期寿命低于5年的患者不太可能从癌症筛查中获得任何生存益处。我们还根据患者因素和测试特征考虑筛查的潜在危害可能性。筛查的一些最大危害是发现了那些永远不会有临床意义的癌症。随着预期寿命的缩短，这种情况更有可能发生。最后，由于许多老年人的癌症筛查决定不能仅仅通过对益处和危害的定量估计来回答，因此根据患者自己的价值观和偏好来考虑估计的结果是做出知情筛查决定的最后一步。
Considerable uncertainty exists about the use of cancer screening tests in older people, as illustrated by the different age cutoffs recommended by various guideline panels. We suggest that a framework to guide individualized cancer screening decisions in older patients may be more useful to the practicing clinician than age guidelines, Like many medical decisions, cancer screening decisions require weighing quantitative information, such as risk of cancer death and likelihood of beneficial and adverse screening outcomes, as well as qualitative factors, such as individual patients' values and preferences, Our framework first anchors decisions through quantitative estimates of life expectancy, risk of cancer death, and screening outcomes based on published data. Potential benefits of screening are presented as the number needed to screen to prevent 1 cancer-specific death, based on the estimated life expectancy during which a patient will be screened. Estimates reveal substantial variability in the likelihood of benefit for patients of similar ages with varying life expectancies. In fact, patients with life expectancies of less than 5 years are unlikely to derive any survival benefit from cancer screening. We also consider the likelihood of potential harm from screening according to patient factors and test characteristics. Some of the greatest harms of screening occur by detecting cancers that would never have become clinically significant. This becomes more likely as life expectancy decreases. Finally, since many cancer screening decisions in older adults cannot be answered solely by quantitative estimates of benefits and harms, considering the estimated outcomes according to the patient's own values and preferences is the final step for making informed screening decisions.