Cancer Treatment Too Often Determined by Age

Age, not overall health or prognosis, plays too large a role in determining what patients get cancer treatment, according to a new study from the San Francisco VA Medical Center and the University of California, San Francisco.

The study focused on more than 20,000 patients 65 and older with non-small-cell lung cancer (NSCLC) and found that younger patients were more likely to receive treatment than older patients, regardless of their health status or chance for improvement.

In fact, for all stages of the cancer, treatment rates decreased more in association with advancing age than with the worsening of other illnesses. As a result, patients between the ages of 65 to 74 who were severely ill from other illnesses received treatment at roughly the same rates as those in the same age range with no comorbidities.

Yet, the authors noted, the patients who were severely ill from other conditions were less likely to benefit and more likely to be harmed from cancer treatment.

“It’s clear that, as human beings and physicians, we fixate on age in deciding whether to pursue cancer treatments, including lung-cancer treatments,” said lead author Sunny Wang, MD, a San Francisco VAMC physician and an assistant clinical professor of medicine at the University of California-San Francisco. “Instead, we should be looking at our patients’ overall state of health.”

The study, based on an analysis of the electronic health records of veterans who were in the VA Central Cancer Registry from 2003 to 2008, was published earlier this year in the Journal of Clinical Oncology.

”The message here is, ‘Don’t base cancer treatment strictly on age,’” said Wang. “Don’t write off an otherwise healthy 75 year old and don’t automatically decide to treat a really ill 65 year old without carefully assessing the risks and benefits for that patient.”

1.  Wang S, Wong ML, Hamilton N, Davoren JB, Jahan TM, Walter LC. Impact of age and comorbidity on non-small-cell lung cancer treatment in older veterans. J Clin Oncol. 2012 May 1;30(13):1447-55. Epub 2012 Mar 26. PubMed PMID: 22454424; PubMed Central PMCID: PMC3383118.

Virtual Colonoscopy Without Laxatives Accurately Detects Large Polyps

Polyps most likely to be precancerous can be detected as accurately with computed tomographic colonography (CTC), also known as virtual colonoscopy, administered without laxatives as conventional colonoscopy, according to joint study from the San Francisco VA Medical Center, the University of California, San Francisco, and Massachusetts General Hospital.

“I think we have demonstrated that laxative-free CTC is a valid tool for detecting polyps that are clinically significant,” said co-author and site principal investigator Judy Yee, MD, chief of radiology at and the San Francisco VAMC and professor and vice chair of radiology at UCSF.

The study, published earlier this year in the Annals of Internal Medicine, looked at 605 patients, aged 50 to 85, to compare the accuracy of laxative-free CTC in detecting lesions 6 millimeters or larger in size to standard optical colonoscopy.

The accuracy rate for laxative-free CTC exams in detecting significant polyps 10 mm or larger was 91% compared with 95% for the convention exams — a difference of no statistical significance, according to Yee.

For both types of colonoscopies, scan sensitivity decreases with polyp size. The study found that, for polyps measuring 6 mm, sensitivity for CTC was 59%, compared with standard colonoscopy at 76%. At the same time, the smaller the polyp, the less likely it is to be cancerous, Yee pointed out, noting that polyps between 6 and 9 mm are not always removed. “Polyps 10 millimeters or larger unquestionably come out,” she said.

With laxative-free CTC, patients do not use laxatives to cleanse the bowel but instead begin a low-fiber diet two days before the test. The day before the exam, they also ingest a tagging agent that mixes with residual material in the colon and can be identified and removed digitally when radiologists interpret the scans.

“The use of laxatives is often viewed as the worse aspect of having not only a virtual colonoscopy but an optical colonoscopy,” said Yee. “I hope that this research will encourage patients who have delayed screening for colon cancer to be examined with this less invasive method.”

During the study, three of the 605 subjects were found to have cancerous polyps, which were identified by both the laxative-free virtual colonoscopy and the standard OC exam.

1.  Zalis ME, Blake MA, Cai W, Hahn PF, Halpern EF, Kazam IG, Keroack M, Magee C,Näppi JJ, Perez-Johnston R, Saltzman JR, Vij A, Yee J, Yoshida H. Diagnostic accuracy of laxative-free computed tomographic colonography for detection of adenomatous polyps in asymptomatic adults: a prospective evaluation. Ann Intern Med. 2012 May 15;156(10):692-702. PubMed PMID: 22586008.

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