August 4, 2020,
Summary, Cécile Bour, MD
Judith Garber, political scientist at the Lown Institute  had already published an interesting article on the opportunity to reduce screening during the Covid period and during lockdown .
In very old age, people are less likely to live long enough to benefit from the advantages of screening, but they are much more exposed to the risks of treatments that will follow the discovery of a lesion that would not have had the time to endanger their lives if it had not been detected. This is why the recommendations, whether American or European, set age limits beyond which screening will not only be useless but potentially harmful.
Judith Garber reminds us the figures of excessive screening in elderly people in a study conducted in 2014 among older patients at very high risk of mortality: 37.5% were screened for breast cancer, 30% were screened for cervical cancer and 40% were screened for colorectal cancer.
The study is published in the JAMA by researchers at the Penn State College of Medicine
Researchers analyzed the data set of more than 175,000 participants and measured the proportion of adults above the recommended age who reported being screened for colorectal cancer (age cutoff of 75 years), cervical cancer screening (age cutoff of 65 years) and breast cancer mammography screening (age cutoff 74 years).
The results are as follows:
- 45% of survey respondents reported having had a colorectal, cervical or breast cancer screening, even though they had exceeded the recommended age for screening set by the USPSTF .
- Overscreening was most common for breast cancer, with 74% of women over 74 years of age having had a mammogram.
- Cervical cancer had the lowest rate of overscreening, with 45.8% of women over 65 years of age,
- Yet 32% of women being overscreened despite a previous hysterectomy.
- Even people with a high mortality risk were no less screened than those with a longer life expectancy.
For breast cancer, there were disparities: women living in metropolitan areas, with good quality health care and in good or excellent health, were more frequently overscreened than women living in rural areas, without an usual source of care and poorer reported health status. (Editor's note: it should be noted that this fact was also reported in a previous study in the state of Sao Paulo in Brazil.  )
Higher levels of education were associated with higher rates of overscreening among women.
What are the reasons for overscreening of older adults and outside of recommendations?
According to the authors of the Penn State College of Medicine study, overscreening for women may be related to residing in urban areas, because women have easier access to screening facilities than women living in rural areas, and are offered more screening, whether or not it is appropriate.
Another hypothesis is that clinicians in rural areas have longer and more trusting relationships with patients, so that they have time to explain to patients why screening is no longer recommended after a certain age.
Judith Garber brings up the interesting theory, which the authors did not raise, that the greater availability of medical facilities in cities, the fact that there are more technological offerings and more competition for patients in urban areas, encourage overuse of the system by medical insurance beneficiaries, and thus unnecessary screening, as a March 2020 study also suggests.
Researchers at the Penn State College Institute are calling for additional research on causes to reduce this persistent trend.
1] The Lown Institute (USA Massachusetts) is a non-profit organization, “a think tank generating bold ideas for a just and caring system for health“
3] an independent U.S. organization of primary care and prevention experts that systematically reviews evidence of effectiveness and develops recommendations.