Time had elapsed since the patient had her last colonoscopy, making her eligible for another screening, explained Steven Itzkowitz, a gastroenterologist from the Icahn School of Medicine at Mount Sinai in New York.
At 85, she was in “reasonable health,” with low risks associated with the procedure—like bleeding, anesthesia reactions, or perforation of the colon—but she faced the dilemma of needing to temporarily stop her blood thinners due to cardiac stents, which could elevate those risks.
If this decision had been made five years earlier, Itzkowitz might have scheduled the screening without much thought. However, more recent studies suggest the benefits of a repeat colonoscopy are minimal after 75.
Now he finds himself questioning, “What’s the point here?”
This sentiment isn’t unique to him; many doctors and patients are reconsidering these choices. The calculations regarding risks and benefits of typical screenings and treatments change considerably with age, highlighting cases that may not be necessary anymore.
Research has recently focused on other issues, like the need for treating specific skin lesions, a common thyroid medication that some older adults can stop using, and colonoscopies that provide limited mortality reduction for colon cancer, making the associated risks potentially outweigh the benefits.
Unpleasant but Likely Harmless
The rough patches on skin known as actinic keratoses often develop due to prolonged sun exposure and typically occur on faces and hands. A significant portion of older patients—nearly 30%—in a recent study were diagnosed with these lesions over five years. But what happens next?
Allison Billi, a dermatologist from the University of Michigan, noted that most of the time, these lesions are removed via methods like cryosurgery or topical treatments. The concern is that they could evolve into cancer. However, she pointed out that “the odds of this progression are less than 1 in 1,000” for most patients without a skin cancer history. Often, these patches fade naturally.
She mentioned that treatment could be more of a hassle than the condition itself, with procedures often being painful and potentially leading to lasting skin issues. The likelihood of recurrence is also high, making her suggest a strategy of active observation instead, where doctors would monitor these lesions for changes rather than routinely removing them. “We don’t always need to intervene,” she added, though sunscreen is still a must.
Questionable Medication
Levothyroxine is a widely prescribed medication for individuals whose thyroid glands fail to produce enough hormone. Hypothyroidism leads to symptoms like weight gain and fatigue. It’s often prescribed even for borderline cases that don’t exhibit any noticeable symptoms, but is it always needed?
Research indicates that in many older adults with subclinical hypothyroidism, hormone levels may revert to normal without treatment. Furthermore, studies show that among older patients, levothyroxine had “no apparent benefit” for symptom relief.
As with any medication, there are risks, including interactions with other commonly taken drugs, regular lab tests, and check-ups, not to mention dietary adjustments required when on the medication. A gradual tapering protocol showed promise for some patients, with about one-quarter of those in a study able to stop taking the drug after a year while maintaining healthy thyroid levels. Yet, it’s crucial that any discontinuation be closely managed by healthcare providers.
Screening Risks
The ongoing debate about when older adults should stop colon cancer screenings has raised critical questions. The U.S. Preventive Services Task Force has labeled the benefits “small” after age 76, and yet many older patients with limited life expectancies still find themselves advised to undergo these screenings.
Samir Gupta, a gastroenterologist, frequently encounters this dilemma. He noted, “I know they have a low risk of colon cancer, and I’m subjecting them to additional risks,” especially since complications can increase with age. Research indicates that nearly 7% of patients over 75 experienced significant complications post-screening.
Gupta recently led a study examining nearly 92,000 veterans over 75 who had previous screenings. It found that while those with prior adenomas were more likely to develop colon cancer, the actual death rate from it remained remarkably low for both groups. The results highlighted that a considerable portion of veterans died from other causes, making the distinction in cancer mortality almost negligible.
Even with a successful procedure, Itzkowitz noted, “you’ll either find nothing or discover something that won’t significantly affect your lifespan.” Still, he remarked that many patients want to continue with colonoscopies after having polyps removed.
Shifting these established medical practices is a challenge. Efforts to “deprescribe” drugs face resistance from both patients and healthcare providers alike. Many older adults continue undergoing screenings that no longer hold substantial benefits.
In the end, when Itzkowitz told his 85-year-old patient she could forgo another colonoscopy, she appeared quite satisfied.
