Targeted therapies attack cancer cells directly.

Unlike standard chemotherapy which targets all

rapidly dividing cells, targeted therapy interferes with specific molecules (e.g., protein
enzymes, growth factor receptors) required for the cancer cells
to replicate. Targeted therapies may be used alone or in com-
bination with chemotherapy (National Cancer Institute, 2012);
they are used for treating advanced colorectal cancer. Side
effects include fatigue, diarrhea, headaches, and alterations in
blood pressure (ACS, 2013b).

SCREENING AND EARLY DETECTION: ISSUES

FOR OLDER ADULTS
Primary prevention of cancer is desirable and is affected by
changes in lifestyle. Older adults are likely to have had a lifetime
of exposure to risk factors, and although changing lifestyles is
advantageous for them, the changes may not reverse the effects
of exposure. Furthermore, changing habits that have developed
over a lifetime is difficult, despite demonstrable benefits. Given
the difficulty of cancer prevention, detection of cancer at an
early stage may greatly improve survival rates. Screening asymp-
tomatic persons at risk is feasible in many common malignan-
cies, including breast, cervical, and colorectal cancers.
When considering a cancer-screening program, the health
care provider should answer two fundamental questions:
1. Is the screening test sensitive? A sensitive test will correctly
identify all screened individuals who have the disease (those
with true-positive results).
2. Is the screening test specific? A specific test identifies all
individuals who do not have the disease (those with true-
negative results).
Current efforts at advancing the science and technology of
screening have resulted in greater accuracy of many screening tests.
The accuracy of screening may be increased by the recognition of
highly sensitive tumor-specific circulating markers (e.g., PSA for
the detection of prostate cancer); the development of imaging
techniques capable of finding smaller lesions (e.g., refinements in
radiographic techniques for mammography); and the identifica-
tion of early molecular changes in cancer specimens (e.g., at the
cellular level using Papanicolaou [Pap] tests for cervical cancer).
Given the limited effectiveness of primary prevention for older adults, screening asymptomatic
persons at risk for cancer may be
the most promising way to reduce the number of cancer deaths in
older adults.
Yet another question to consider with a screening program
is the prevalence of the disease in the population. The more
prevalent the disease, the more beneficial a screening program
will be. Because cancer is more common in older adults, screen-
ing is generally beneficial. The incidence of cancer increases
with age; thus, the positive predictive value of screening tests
(i.e., the proportion of persons screened who actually have the
disease) is likely to increase. In addition, screening older adults
who have comorbid conditions at the time of cancer diagnosis
may result in elective treatment at an early stage of disease, thus
reducing the possibility of serious treatment-related morbidity
and deaths.
Recommendations on planning major screening programs
for older adults should be made with caution. Screening guide-
lines vary greatly among different national organizations.
Differences among recommendations are caused by the lack of
cancer screening trials that include older adults. Because more
than 56% of all cancers are diagnosed in those older than 65
and 70% of all cancer deaths occur in this age group, the lack of
evidence-based criteria for screening older adults makes choos-
ing screening protocols difficult. A decision-making process that
takes into account each older adult's personal preference and
health should be used rather than relying only on age guidelines
for cancer screening and detection methods. Screening should
not be conducted in the absence of intent or ability to follow up
on the findings with more complete evaluation and treatment.
Screening is costly and useless if no follow-up occurs. Other fac-
tors that influence the decision to screen an older adult include
comorbidity, functional ability, and life expectancy.
Considerable uncertainty exists concerning the use of cancer
screening tests in older adults, as illustrated by the different age
cutolls recommended by various guideline panels. A frame-
work to guide individualized cancer screening decisions in older
patients may be more useful to the practicing nurse than age
guideline. like many mcdical decisions, cancer screening deci-
sions require weighing quantitative information such as risk of
cancel death and likelihood of beneficial and adverse screen-
ing outcomes, as well as qualitative factors such as individual
patients' values and preferences.
Potential benefits of screening-are presented as the number
needed to screen to prevent one cancer-specific death, based
on the estimated life expectancy during which a patient will
be screened. Estimates reveal substantial variability in the like-
lihood of benefit for patients of similar ages with varying life
expectancies. In fact, patients with life expectancies of less than
5 years are unlikely to derive any survival benefit from cancer
screening. The likelihood of potential harm from screening
according to patient factors and test characteristics must also
be considered. Some of the greatest harms of screening occur by
detecting cancers that would never have become clinically sig-
nificant. This becomes more likely as life expectancy decreases
(Reeve, Potosky, Smith, et al., 2009).
Finally, because many cancer screening decisions in older
adults cannot be made solely on the basis of quantitative
estimates of benefits and harms, considering the estimated out
comes according to the patient's own values and preferences
is the final step in making informed screening decisions. as
more and more cancers occur in older people,oncologists are
increasingly confronted with the necessity of integrating geriatric
parameters into the treatment of their patients.
The International Society of Geriatric Oncology (SIOG) cre
ated a task force to review the evidence on the use of a
comprehensive geriatric assessment (CGA) in cancer patients. a
systematic review of the evidence was conducted,several biologic and clinical correlates of aging
were identified strong
evidence suggests that a CGA may detect many problems missed by
a regular assessment in both general geriatric patients and older
patients with cancer. Strong evidence also exists that CGA
improves function and reduces hospitalization in older adults
A CGA, with or without screening and with follow-up, should
be used in older patients with cancer to detect unaddressed
problems, improve functional status, and possibly improve the
chances of survival (Extermann, Aapro, Bernabei,et.,2005)
Although CGA is a multidimensional tool designed to detect
health problems, a barrier to its use in busy health care settings
is the length of time required to complete the entire intire instrument.
Overcash, Beckstead, Extermann, & Cobb (2005) conducted
a study to determine what items contained in the instrument
could be compiled to construct an abbreviated CGA (aCGA)
A retrospective chart review of more than 500 patients with
cancer was performed at a large southeastern cancer center
Statistical analyses revealed 15 valid and reliable items that form
the aCGA. They concluded that an aCGA may be helpful in
screening those seniors who would benefit from the full-lengh
CGA.
Walter and Covinsky (2001) developed a framework
for cancer screening in older adults with the following
recommendations:
• Individualize the decision by conducting a comprehensive
geriatric assessment thai includes an evaluation of comorbi
conditions, polypharmacy, and the presence of dementia of
depression.
• Estimate life expectancy. Reducing the risk of dying of a
detectable cancer should be the main benefit of cancer
screening. Although an exact determination of longevity is
impossible, decisions can be made on the basis of undder
standing the distribution of life expectancies at various ages
The goal of any cancer screening program is to detect that
cancers early enough for successful treatment. Therefore,
patient with more than 5 years' life expectancy will benefit
from a cancer-screening program. Although determining
life expectancy for a particular individual is difficult,some
attempt should be made to correlate life expectancy with the
potential for future development of a specific cancer,the
decision to screen should consider the treatment impo
tions, but the decisions concerning specific treatment and
 how aggressively to treat are separate, and take place after the type and stage of cancer are
diagnosed.
• Assess the risk of cancer screening. Certain clinically unim
portant cancers increase as people age; therefore,older
patients are frequently diagnosed with these types of cancer
 Older people have more cognitive and physical condi
tions that increase their fear of cancer screening. Ascertain
patient preferences. Consider each older person's approach
to health and discuss the risks and benefits of cancer
screening tests.
 Consult various cancer screening guidelines. The U.S.
preventive Services Task Force (USPSTF) guidelines are the
most widely used and respected; however, these guidelines
are very conservative and differ significantly from those of
specialty organizations such as the ACS and the AGS. A list-
ing of all USPSTF guidelines is provided at http://www.ahrq.
gov/clinic/uspstfix.htm.
Ideally, effective cancer screening programs should lead to an
overall reduction of canccr-related deaths and higher detection
fates and prolonged survival times when cancer is diagnosed at
an early stage. However, controversy has recently surrounded
much of the research that citcs the benefits of screening. Several
notes of caution should be considered when the results of
screening programs are reviewed (Yates, 1992):
• Screening programs may sometimes appear to prolong sur-
vival only because of early detection of a cancer, without any
actual extension of life as a result of early treatment. This is
known as lead-time bias; a cancer that has a natural history
of 5 years may appear to gain a 2-year survival advantage
because of diagnosis at year 1 of tumor growth instead of
year 3.
• Screening favors the early detection of the more slowly grow-
ing and less malignant neoplasms, which leads to the appear-
ance of improved survival rates; however, screening actually
only increases the detection of the least aggressive cancers.
This is known as length bias. Length bias appears to improve
survival rates but actually dilutes the real effect of screening
programs.
• Of particular importance when older adults are screened is
that screening allows the diagnosis of cancers that would not
have become clinically relevant during the persons lifetime,
this is known as overdetectior. bias.
These controversies underscore the notion that recommen-
dations for screening require individual consideration. In addi-
tion to the controversies surrounding screening research, other
factors may impede screening efforts for older adults. Older
adults are often seen for episodic events in the context of chronic
illnesses managed by medical specialists. Preventive services
may not be appropriate at the time of an acute episode or may
not be available within a specialty practice; therefore, screening
procedures may not be offered. If they are offered, older adults
may choosc not to participate because they lack information
about cancer screening, including the rationale, recommended
frequency, and specific procedures. Aging and minority status
have been linked to rcduced knowledge of and access to cancer
screening through mammography, rectal examination, fecal
occult blood testing, Pap testing, and proctoscopy (Beydoun &
Beydoun, 2008; Casey, Call, & Klinger, 2000; Yates, 1992) (see
the two Evidence-Based Practice boxes). In addition to lack of
knowledge, older adults may fear the diagnosis of cancer and
the associated treatments, or they may be unable or unwilling to
pay for health care services.