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New York Times: Life Expectancy – Not Just Age – Needs to Be Part of Your Health Decisions as You Grow Older

As we grow older, we become accustomed to the idea that the medical tests and treatments our physician recommends tend to change with age. Conventional medical wisdom has it that, after a certain age, certain tests might no longer be recommended – mammograms, prostate exams, colonoscopies and so on. The argument seems to imply that there’s little point in testing for a health condition at age 80 that you don’t plan to do anything about.

But a growing number of voices in the medical community are challenging those age-based assumptions. Instead of looking only at an arbitrary number – a patient’s age – to determine a course of treatment, there’s another number that is far more relevant: the patient’s life expectancy, which is based not just on current age but also on lifestyle, heredity, and overall health.

We were intrigued by this idea, described in this New York Times article written by reporter Paula Span. She describes a shifting landscape of medical care in which doctors are taking a more individualized view of which tests and treatments to recommend to older patients. Our take-away: don’t be surprised if your physician might be having a change of heart about the tests that he or she prescribes for you. (Please note that a subscription may be required to access the New York Times article.)

Age Alone Has Been the Criterion for Tests

Span begins her article by profiling a hypothetical female patient, age 76. At this age, most doctors will ask their female patients if they want to continue with regular mammograms (since the recommended age range for mammograms is 40 to 74), and most will likely not perform colonoscopies. This age-related guideline is standard medical practice, Span suggests.

However, as the New York Times article points out, medical experts increasingly agree that these age ranges are arbitrary and possibly outdated. Even the independent and influential U.S. Preventive Services Task Force, in its latest draft guidelines, says “the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women age 75 years or older.”

Colonoscopies are a similar story. The task force gives testing for colorectal cancer a C grade for those 76 to 85, meaning there’s “at least moderate certainty that the net benefit is small.” It should only be offered selectively, the guidelines say. But is that the whole story? Based on the article, views within the world of medicine are shifting.

New View: Life Expectancy Has to be Considered

Skeptics of using age alone as the standard for deciding which medical tests are no longer necessary are asking, what exactly does the number of a person’s age really have to do with their overall health?

For example, in her New York Times piece, Span reflects on her hypothetical 76-year-old patient. “What else is true about this hypothetical woman? Is she playing tennis twice a week? Does she have heart disease? Did her parents live well into their 90s? Does she smoke?”

Span adds, “Any or all such factors affect her life expectancy, which in turn could make future cancer screenings either useful, pointless or actually harmful. The same considerations apply to an array of health decisions at older ages, including those involving drug regimens, surgeries, other treatments and screenings.”

Dr. Steven Woloshin, internist and director of the Center for Medicine and Media at the Dartmouth Institute, says, “It doesn’t make sense to draw these lines by age. It’s age plus other factors that limit your life.”

Some Experts Starting to Change Their Tune

Because of this, attitudes in the medical field are slowly changing in favor of basing testing guidelines on life expectancy. “Life expectancy gives us more information than age alone,” says Dr. Sei Lee, a geriatrician at the University of California, San Francisco. “It leads to better decision making more often.”

Recent medical task force recommendations are starting to reflect this broader view. “For older people undergoing lung cancer tests, for instance, the guidelines advise considering factors like smoking history and ‘a health problem that substantially limits life expectancy’ in deciding when to discontinue screening,” Span writes. “The task force’s colorectal screening guidelines call for considering an older patient’s ‘health status (e.g., life expectancy, co-morbid conditions), prior screening status and individual preferences.’”

Similarly, the American College of Physicians incorporates life expectancy into its prostate cancer screening guidelines; so does the American Cancer Society, in its guidelines for breast cancer screening for women over 55.

How Can Life Expectancy be Predicted?

This is all well and good, but how does anyone know how long they will live? The stats reflect huge variation across age and levels of health.

Dr. Eric Widera, a San Francisco-based geriatrician, analyzed census data from 2019. “The data shows that the least healthy 75-year-olds, those in the lowest 10 percent, were likely to die in about three years,” Span explains of his findings. “Those in the top 10 percent would probably live for another 20 or so. All these predictions are based on averages and can’t pinpoint life expectancy for individuals.”

That said, risk factors can be used by both doctors and laymen alike to get a ballpark idea of how many years they can be expected to live. 

Online Calculators Offer Guidance

“For instance,” Span writes, “Dr. Woloshin and his late wife and research partner, Dr. Lisa Schwartz, helped the National Cancer Institute develop the Know Your Chances calculator, which went online in 2015. Initially, it used age, sex and race (but only two, Black or white, because of limited data) to predict the odds of dying from specific common diseases and the odds of mortality overall over a span of five to 20 years.”

She adds, “The institute recently revised the calculator to add smoking status, a critical factor in life expectancy and one that, unlike the other criteria, users have some control over.”

Dr. Barnett Kramer, an oncologist who worked with the team who developed the calculator, says, “Personal choices are driven by priorities and fears, but objective information can help inform those decisions.” He called this “an antidote to some of the fear-mongering campaigns that patients see all the time on television,” courtesy of drug manufacturers, medical organizations, advocacy groups and alarmist media reports. “The more information they can glean from these tables, the more they can arm themselves against health care choices that don’t help them.”

“Unnecessary testing,” he adds, “can lead to overdiagnosis and overtreatment.”

Some Calculators are Disease-Specific

There are a number of health institutions and groups that provide disease-specific online calculators, and Span lists a few in her article. But ultimately, calculators that look at single diseases don’t give the proper context by comparing the risk of mortality from other causes.

“Probably the broadest online tool for estimating life expectancy in older adults is ePrognosis, developed in 2011 by Dr. Widera, Dr. Lee and several other geriatricians and researchers,” Span writes. “Intended for use by health care professionals but also available to consumers, it offers about two dozen validated geriatric scales that estimate mortality and disability.”

These calculators, some for patients living alone and some for those in nursing homes or hospital settings, use considerable information about health history and current functioning.

“Helpfully, there’s a ‘time to benefit’ instrument that illustrates which screenings and interventions may remain useful at specific life expectancies,” Span adds.

Calculators Can Help Guide Medical Choices

Span then returns to our hypothetical 76-year-old female patient. “If she’s a healthy never-smoker who is experiencing no problems with daily activities and is able, among other things, to walk a quarter mile without difficulty, a mortality scale on ePrognosis shows that her extended life expectancy makes mammography a reasonable choice, regardless of what age guidelines say,” Span explains.

In this case, she would be a victim of undertreating if her doctor were to cut off mammography based on her age.

“If she’s a former smoker with lung disease, diabetes and limited mobility, on the other hand, the calculator indicates that while she probably should continue taking a statin, she can end breast cancer screening,” Span writes. “‘Competing mortality’ — the chance that another illness will cause her death before the one being screened for — means that she will probably not live long enough to see a benefit.”

Life Expectancy is “a Guide, Not a Limit” to Care

All of this being said, the truth is that patients ultimately have to make decisions on their own, and they can choose to use life expectancy as a guide or not.

“Some older people don’t ever want to stop screenings, even when the data shows they’re no longer helpful,” Span writes. “And some have exactly zero interest in discussing their life expectancy; so do some of their doctors. Either party can over- or underestimate risks and benefits.”

The tools are there to give valuable context beyond age to those who prefer to make their health decisions through evidence-based calculations. Dr. Woloshin says that when considering life expectancy, “You’ll know what to focus on, as opposed to being frightened by whatever’s in the news that day. It anchors you.”

As always, though, any decisions should be made with your medical provider’s involvement. Dr. Woloshin adds, “This is meant to be a jumping-off point for conversations. It’s possible to make much more informed decisions — but you need some help.”

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(originally reported at www.nytimes.com)

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