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Invited Commentary |

Discussing Long-term Prognosis in Primary Care Hard but Necessary

Mara A. Schonberg, MD, MPH1; Alexander K. Smith, MD, MS, MPH2,3
[+] Author Affiliations
1Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
2Division of Geriatrics, Department of Medicine, University of California, San Francisco
3San Francisco VA Medical Center, San Francisco, California
JAMA Intern Med. 2016;176(5):678-680. doi:10.1001/jamainternmed.2016.0972.
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Primary care practitioners (PCPs), including physicians and nurse practitioners, strongly influence whether older adults are screened for cancer, treated aggressively for diabetes mellitus, and/or given statins for primary prevention of cardiovascular disease. Meanwhile, guidelines1 increasingly encourage PCPs to consider patient life expectancy when deciding whether to recommend these and other medical interventions to older adults. For example, several organizations recommend that older adults with less than a 10-year life expectancy not be screened for cancer.2 The rationale for this recommendation is that these patients will not live long enough to experience the possible life-prolonging benefits of cancer screening. Instead, screening these patients only puts them at risk of the harms associated with the tests, including anxiety resulting from false-positive test results, overdiagnosis (detection of tumors that are of no threat), and complications from workup and/or treatment of cancer.3 Despite the guidelines and the risks of cancer screening, nearly half of older adults with short life expectancies are screened for breast (women only) or colon cancer.4 One reason for this overuse of cancer screening and other medical interventions among older adults with short life expectancy is that PCPs tend to avoid discussing prognosis with older adults.

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