Canadians use 80 per cent of their healthcare in the last 20 per cent of their lives. Even the healthiest adults begin to decline after the age of 40, on almost every measure of healthcare fitness. The number and severity of healthcare problems begin to increase for cholesterol, heart disease, arthritis, hearing, vision, muscle tone, and respiration, to name a few. And cancer is known primarily as a disease of the elderly.
Despite common statements that 50 is the new 40 or 70 is the new 60, our bodies tell us otherwise. How we look and feel do not necessarily reflect how our body is changing with each year. This is both good news and bad.
The good news is that advances in medicine have made diagnosis earlier for diseases and conditions that previously were untreatable. Advances have also extended survival rates for some of the most complex and previously deadly illnesses, including certain cancers and complex heart disease.
The bad news? With advances in technology in both laboratories and imaging, we become VOMITs. It’s an acronym for Victims of Medical Imaging Technology. Almost every imaging, whether x-ray, ultrasound, CT or PET scan reveals some abnormality that was previously not known in the patient.
Sarcastically-sounding but seriously-named incidentalomas abound. This is the term used to describe the discovery of an array of non-threatening cysts and tumours that show up, often when the imaging is prescribed for another purpose.
For example, an ultrasound of a patient’s abdomen, prescribed because of non-specific stomach pain, can reveal a benign tumour on the kidney.
The irony is that follow-up scans for incidentalomas increase the patient’s exposure to radiation, which can also cause cancer. Moreover, incidentalomas may cause stress to the patient and the physician, further encouraging varying follow-ups to reassure both. There are guidelines for follow-ups of incidentalomas; however, further treatments must take into account a risk-versus-reward review.
Over time, what was once considered a best-practice involving medical imaging might change. An example is the position on routine mammograms for early detection of breast cancer. At present, the Canadian Cancer Society (CCS) recommends a mammogram every 2 years between ages 40 and 74 for women and trans, non-binary and gender-diverse people at average risk.
The rationale of the CCS to begin screening at age 40 is that mammogram results may suggest breast cancer even though cancer is not present (called a false positive), especially in younger women. For those 75 or older, a discussion between the patient and the healthcare provider should help decide whether continuing mammograms are appropriate.
Unfortunately, not every province or territory offers mammograms for those in their 40s. The dates for inclusion are set by each jurisdiction. Similarly, mammogram guidelines differ across international boundaries, including between Canada and the United States. In the US, the national cancer organization encourages optional annual screening between 40 and 44 and recommends annual screening between 45 and 54. It further recommends that “women 55 and older can switch to a mammogram every other year, or they can choose to continue yearly mammograms. Screening should continue as long as a woman is in good health and is expected to live at least 10 more years.”
In another change regarding breast cancer detection, earlier campaigns for monthly BSE (breast self-examination) in both Canada and the U.S. have now changed to encourage women to be familiar with their breasts in general and to have CBE (clinical breast examinations) on a regular basis.
Medical recommendations change for men, as well. PSA tests are a good example. Just as a large cohort of baby-boomer men were becoming middle-aged, PSA tests were recommended, along with digital examinations. This is no longer the case. The rationale is best explained by the Canadian Cancer Society’s summary that “although PSA testing may find prostate cancer early, research has shown that it still may not reduce the chance of dying from prostate cancer.”
Changes in guidelines for breast and prostate cancer are important not just because they reflect ongoing research on diagnosis, treatment and survival. They are also significant because they are the two most common cancers, based on sex assigned at birth. For 2024, the Canadian Cancer Society projects some 27,900 new cases of prostate cancer and some 30,500 new cases of breast cancer. Together, that’s almost seven new cases diagnosed every hour of every day.
The positions of the Canadian Cancer Society on breast and prostate cancer screening, important as they are, also highlight the jurisdictional issues in providing healthcare across Canada. Some differences in coverage by individual provinces and territories can be explained by demographics. Just as cancer, for example, is not a single disease, the ages and cultural/national histories of different populations present different incidence rates of different cancers in different parts of the country.
Certain population groups carry genetic anomalies more likely to lead to cancer. Again, breast and prostate cancer are more prevalent among populations that have married within their own society over generations. This allows a genetic mutation to become more common. And this, in turn, shows up as higher rates of particular cancers in people with a particular genetic background. When larger groups of such populations are located in one jurisdiction, the resulting guidelines for screening can be affected.
Is there a way to avoid becoming a VOMIT and having a body containing incidentalomas? Again, the answer is not clear-cut.
The most obvious way to avoid these situations is not to be referred for imaging in the first place. There are Canadians who avoid medical care for religious and/or philosophical reasons. There are also Canadians who have had negative experiences (either personally or for a family member or friend) and who do not trust that their experiences will be more positive.
And it is not surprising that the lack of family practitioners and nurse practitioners keeps many people from accessing referrals for specialty care. Access is also an issue for those in non-urban areas. Since COVID, it is estimated that some seven million Canadians do not have a primary care provider.
But for Canadians who are living longer, referrals for imaging (and laboratory) testing are common whenever patients see a healthcare provider. Many seniors have rosters of specialist physicians they see on a regular basis. These visits, plus visits for physiotherapy, massage, acupuncture and occupational therapy, support the concept that healthcare is almost a social activity for older adults.
Invariably, some of the tests will identify incidentalomas. Which will lead to more follow-ups. Each Canadian has to decide on the risk/reward scenario based on their personal preferences and healthcare.
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