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Unwarranted Cancer Screening: A Teachable Moment.

Story From the Front Lines A 70-year-old male nursing home resident with a history of benign prostatic hyperplasia and moderate dementia saw his primary care physician for a routine visit. His screening prostate-specific antigen (PSA) level was found to be slightly elevated to 6.7 ng/mL; a repeated PSA test 2 months later revealed a level of 18.2 ng/mL. The patient was referred to urology to address concerns about an aggressive prostate cancer. A computed tomographic (CT) scan of the abdomen and pelvis revealed a 5.1-cm mass in the ascending colon with adjacent lymphadenopathy, multiple liver lesions, and sclerotic foci in the pelvic bones—all consistent with metastatic colon cancer. His urologist referred him to a gastroenterologist, who deferred further intervention pending a discussion with the primary care physician. Notably, the patient had clinically significant functional limitations, requiring extensive assistance for most of his activities of daily living. The nursing home staff described him as “sociable, but easily upset,” and generally unable to sustain coherent conversations. The primary care physician spoke with the patient’s sister, who was his legal guardian. She elected to pursue a diagnostic colonoscopy. The procedure was undertaken but aborted owing to retained stool in the distal colon. The patient was then admitted to the hospital to prepare for a repeated colonoscopy. His inpatient internal medicine team considered using a nasogastric tube and mechanical restraints to complete the preparation. However, the patient appeared to be in marked psychological distress merely from being out of his usual environment, and the attending internist thus decided against pursuing these interventions. The patient was eventually able to complete the bowel preparation with considerable encouragement from his bedside nurse. His biopsy results revealed a tubulovillous adenoma with high-grade dysplasia; however, there were positive margins and staging could not be determined. A subsequent CT-guided liver biopsy confirmed that his lesions were metastatic colon cancer. A consulting oncologist suggested that chemotherapy for this stage of cancer would at best offer palliation and recommended against it. A general surgeon recommended against a diverting ileostomy, fearing that the patient was likely to manipulate an ostomy and potentially cause harm. The patient experienced no symptoms due to his metastatic cancer, although he did experience a pulmonary embolism prior to his death 10 months later. His sister remarked that he had notable depressive symptoms following his hospitalizations for these diagnostic procedures. She shared, “While he doesn’t relate to things the way you and I do, he does understand the word cancer, and it’s very disturbing to him.” Teachable Moment Our patient’s case demonstrates the cascade of events that can result from unnecessary testing. A growing consensus recommends using prognostic calculators to estimate a patient’s life expectancy when deciding whether to screen for cancer, and weighing this against the time required for a test to prolong life, known as the “time-to-benefit.”1 Despite these recommendations, between one-third and one-half of patients with high risk of short-term mortality nonetheless receive screening tests.2 Prostate cancer screening in particular has been the subject of scrutiny; both the US Preventive Services Task Force and the American College of Physicians now recommend against screening for prostate cancer in older men.3 This recommendation partially stems from the poor specificity of the PSA test to detect aggressive malignant neoplasms, particularly in patients with benign prostatic hypertrophy.4 Our patient’s comorbidities and poor functional status thus made an elevated PSA level a poor predictor of the presence of a life-limiting prostatic neoplasm. The workup for this patient’s elevated PSA level led to the performance of 3 invasive tests—2 colonoscopies and a liver biopsy. These tests were all performed to confirm a strongly suspected diagnosis of metastatic colon cancer, with no other compelling diagnoses in the differential. Furthermore, these procedures were unlikely to change the treatment course, as our patient’s poor functional status precluded both surgery and chemotherapy. It is worth noting that he never experienced symptoms related to his colon cancer. It is unclear, then, what benefit these procedures provided. While his sister indicated that it was comforting to know the pathological diagnosis with confidence, this knowledge did not change the therapeutic options that were available. Notably, invasive diagnostic tests are likely to have poorer-quality results in patients with conditions that limit their cooperation. One retrospective study found that the presence of stroke or dementia was an independent predictor of inadequate colonoscopy preparation (P < .05); 40% of patients with a history of stroke or dementia who underwent colonoscopies had inadequate preparation and thus inconclusive/nondiagnostic results.5 We encourage physicians to choose wisely and consider the following prior to ordering any test: (1) the potential harms of the test, (2) the potential impact of test results on the treatment plan, and (3) the test’s reliability. This is particularly true in patients with dementia, for whom even minor tests may result in extreme physical discomfort and psychological distress. TEACHABLE MOMENT