providers, recognizing that the expected benefit of early detection declines with remaining life expectancy, consciously decide to discontinue screening following a serious health event.36,37 The USPSTF recommends biennial screening mammography for women up to age 74.37
Cervical cancer screening
The ACS, in collaboration with the American Society for Colposcopy and Cervical Pathology and the American Society for Clinical Pathology, as well as the NCCN, recommend cervical cancer screening for women to age 65, with an emphasis on the incorporation of HPV testing in addition to the Pap test to age 65.35 Women 65 and over who have had three or more consecutive negative Pap tests or at least two consecutive negative HPV and Pap tests within the past 10 years, with the most recent test occurring in the past 5 years, should stop cervical cancer screening. Women who have had a hysterectomy for benign reasons can stop cervical cancer screening. The USPSTF recommends against screening for cervical cancer in women older than 65 who have had adequate prior screening and are not otherwise at high risk for cervical cancer.38 The USPSTF notes that screening may be clinically indicated in older women with an inadequate or unknown screening history or at increased risk, such as women with a history of high‐grade precancerous lesions or cervical cancer, in utero exposure to diethylstilbestrol, or a compromised immune system.
Colon cancer screening
Regular screening with a structural examination of the colon is one of the most effective means of preventing colorectal cancer.35 This is because most polyps or growths can be found and removed before they have a chance to turn into cancer. The clinician’s choice of screening procedure for colon cancer depends on extrinsic factors (e.g. transportation, availability of a gastroenterologist, the patient’s willingness to do one procedure over the other, and the patient’s health status). It is recommended that clinicians consider ordering screening colonoscopies for their Robust patients based on current guidelines and the number of years it takes for polyps to turn into cancer. Primary care physicians may choose to limit screening in Frail individuals or patients with dementia.39
The recommendation for colorectal screening intervals depends on the type of screening examination. This is a potential source of confusion for patients and clinicians.35 Clinicians should discuss the strengths and limitations of various examinations, including that structural examinations are more likely to detect polyps, which can be removed, thereby preventing the development of malignancy; and faecal tests are more likely to detect malignancies, hopefully early, so treatment is associated with less morbidity. The USPSTF and NCCN recommend screening for colorectal cancer starting at age 50 and the ACS at 45. All three recommend colorectal cancer screening in adults age 76–85, but the decision should be an individual one considering the patient’s overall health and prior screening history.35,39,40 The USPSTF, ACS, and NCCN support a faecal occult blood test (FOBT) or faecal immunochemical test‐multi‐target stool DNA test (FIT‐DNA) every three years or flexible sigmoidoscopy every five years. Colonoscopy is a more thorough examination and is the preferred option for screening.35
Prostate cancer screening
The biggest controversy in prostate screening is that some prostate cancers grow slowly and would never cause any problems.37 Because of an elevated prostate‐specific antigen (PSA) test, men may be diagnosed and treated for prostate cancer with either surgery or radiation for lesions that would not cause symptoms or lead to their death. These treatments have side effects that can seriously affect a man’s quality of life. No major scientific or medical organization, including the ACS, American Urologic Association (AUA), USPSTF, American Academy of Family Physicians, and American College of Preventive Medicine, supports routine testing for prostate cancer at this time.35
The ACS recommends that beginning at age 50, men who are at average risk of prostate cancer and have a life expectancy of at least 10 years have a conversation with their healthcare provider about the benefits and limitations of PSA testing and make an informed decision about whether to be tested based on their personal values or preferences.35 The NCCN guidelines focus on men at an increased risk for developing prostate cancer due especially to family history and race and state that PSA testing should only be offered to men with a life expectancy of 10 or more years.41 The USPSTF recommends against prostate cancer screening in men 70 and older.41 These organizations emphasize the need for healthcare professionals to discuss with the male patient the possible benefits and side effects of treatment and answer questions about early prostate cancer detection. Therefore, men who are at least 50 (and younger, if at higher risk) can make informed decisions, taking into account their own situations.
Lung cancer screening
Screening with low‐dose spiral computed tomography (LDCT) has been shown to reduce lung cancer mortality by about 20% compared to standard chest X‐ray among current or former (quit within 15 years) heavy smokers.35 The ACS recommends annual screening for lung cancer with LDCT in adults 55 to 74 years of age who are current or former heavy smokers (at least 30 pack‐years) and in relatively good health who have received evidence‐based smoking‐cessation counselling (if they are current smokers) and have undergone a process of informed/shared decision‐making that included a description of the potential benefits, limitations, and harms associated with lung cancer screening. The NCCN recommendation is the same, except the age to stop is 77; and the USPSTF recommends screening annually from age 55 to 80.42,43 The ACS emphasizes the LDCT is not an alternative to smoking cessation, and smoking cessation should be a priority and emphasized at each patient encounter. All three organizations state that screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.35,42,43
Osteoporosis
The recommendation to screen at least once for patients in all categories except End of Life is based on studies that show inadequate rates of diagnosis and treatment. However, there is no evidence to show that mass screening of elderly women and men for osteoporosis will reduce cost or improve outcomes.44
Dual‐energy X‐ray absorptiometry (DXA) is the current gold standard test for diagnosing osteoporosis in people without a known osteoporotic fracture. It is, however, an imperfect test, diagnosing osteoporosis in less than half of people who progressed to have osteoporotic fractures.47 The WHO fracture risk algorithm (FRAX) should be used to improve diagnostic accuracy. It predicts a 10‐year probability of fracture in men and women who have clinical risk factors: age, gender, previous fracture, femoral neck bone mineral density, bone mass index, prior corticosteroid use, history of rheumatoid arthritis, parental history of hip fracture, and current history of smoking and alcohol use.44,45 The osteoporosis self‐assessment screening tool (OST) and the calcaneal ultrasound are both being evaluated to determine their potential role in better diagnosis of osteoporosis. The USPSTF recommends screening women at age 65 and women at age 60 with risk factors for osteoporosis. The frequency of screening and the age at which to stop screening are not known. The ACP recommends screening for men using DXA starting at age 70 (or younger for men with risk factors: low body weight, physical inactivity, chronic glucocorticoid use, previous fragility fracture, and hypogonadism).
Cholesterol screening
The reason for a low‐level recommendation (i.e. ‘Consider’) and a targeted approach (only for the Robust and Frail with additional risk factors) for cholesterol screening is because there is limited evidence about primary prevention of coronary heart disease using drugs in older populations. However, there are recommendations by organizations for secondary prevention of coronary heart disease in the elderly. The USPSTF recommends screening individuals 65 or older with coronary risk factors because studies have shown a reduction in coronary events on treating patients with statins compared with placebo. The National Cholesterol Educational Program reaffirms the position that older people who are