A few privileges come with growing older, but they often come at a price. One near certainty is an increasing need for medical care.
Indeed, the older we are, the more we spend on healthcare. With the exception of a bump for women during childbearing years, spending steadily increases from around age 5 to the mid-90’s. That’s pretty inclusive.
Knowing this is the typical pattern, retirees must consider whether healthcare interventions are really worth it. This is a personal question, of course. Ninety-one year-old Norma, who recently passed away, chose to travel the country with her children rather than pursue aggressive cancer treatment. A guest on Freakonomics Radio proposes insurance companies pay people with terminal illness to give medical treatment a pass.
I am not advocating these choices for any one individual, or for broad application. The insurance payment scheme in particular presents some disturbing ethical issues. Norma freely chose to skip the chemo and jump on her son’s RV. Other people might make the same choice if they had the option to use medical insurance money for a similar purpose. But they might also be pressured by unscrupulous relatives to take cash over medical care. The insurance company itself might do the persuading.
Even so, these ideas highlight an important fact: people are talking about the issue. Will aggressive medical treatment at the end of life help us live the life we want? Atul Gwande addresses this topic in “Being Mortal.” He suggests medical care should be less about surviving at all costs, and more about living the life we want. Gilbert Welch suggests much the same in “Less Medicine, More Health.”
The emerging idea is that we must all evaluate healthcare choices in light of how they can help us achieve our goals. Even the most benign intervention can lead to a cascade of medical tests, treatments, and procedures. Some can end in disaster.
Consider the screening colonoscopy. Colonoscopy is widely accepted as an important screening test for individuals over age 50. It looks for colon polyps and evidence of colon cancer. A polyp takes about 10 to 15 years to become cancer, so if you follow the current recommendations and have the test every ten years, you can theoretically prevent most colon cancers.
But when do you say no to more colonoscopies? At age 70? 75? 80? Never?
If we all had a crystal ball it would be easy to answer that question. Instead, we must play the odds. For any given age, how likely will we be to develop a life-threatening colon cancer before some other health issue takes us out? And what’s the chance that the colonoscopy – an invasive procedure – will cause its own problems?
As I write this I realize how similar this is to saving for retirement. How likely are you to run out of money before you die? Absent a crystal ball, research is a good start to help answer these questions. A recent study in the Annals of Internal Medicine attempted an answer.
Researchers looked at 355,000 Medicare beneficiaries aged 70 to 79. Half the group received screening colonoscopy, and half did not. In those aged 70 to 74, there was a modest decrease in the incidence of colon cancer after eight years in the screened group - 2.19 percent vs. 2.67 percent in the unscreened group. In addition, there was an adverse event within 30 days of the colonoscopy in 5.6 out of every 1,000 individuals screened. This number includes things like infection and bowel perforation.
In the older group, aged 75-79, the benefit decreased, and the risk increased. Of those screened, 2.84 percent were found to have colon cancer after 8 years, compared to 2.97 percent of the unscreened group. In this age group, 10.3 out of every 1,000 screened individuals developed complications within 30 days of the colonoscopy.
Researchers concluded that screening colonoscopy offered a “modest” benefit to the 70-74 year old age group, and a still smaller benefit to the older group.
So what do you do? Medicare will pay for your screening colonoscopy with no upper age limit. They will buy you a colonoscopy for your 100th birthday if you can find a doctor to perform one. Money isn’t the main factor here.
But your goals are a factor. Do you want to take the risk of complications at age 75 to know you will gain a marginally better chance of avoiding colon cancer until you are 85? Or would you rather forget about it and carry on with your life, and if cancer is the thing that finally comes and gets you, so be it?
No single answer works for everyone. My guess is that what seems like a good plan at 60 or 65 may not seem so clear cut at 70 or 75. But whether you are considering colonoscopy or any other medical procedure, it’s best to know the risks - for today and tomorrow - as well as the benefits.
Amy Rogers MD is not a practicing physician and nothing written here should be taken as medical advice from either Amy or AssetBuilder. Medical decisions should be made with care in consultation with your health care provider.