Why DOES the NHS impose age limits on health screening that could save older people’s lives?
For lung cancer it’s 74. For breast cancer, 70. And for cervical cancer it’s just 64. So...
WAITING for the results of a chest scan last year, Diane Galloway was braced for a diagnosis of a serious lung condition. A smoker for 20 years, she’d had a persistent cough for six months and had been referred by her GP for an X-ray, then a CT scan of her chest and abdomen to try to get to the bottom of it.
But when the results came back, they were not what Diane, now 79, expected.
To her relief, there was no sign of cancer, but although there was some damage to her left lung, the more pressing problem was an aneurysm — a bulge in the aorta in her abdomen — which needed urgent, life-saving treatment.
The aorta is the main blood vessel in the body, running from the heart and into the abdomen.
Normally by the point it reaches the abdomen, it’s around 2 cm in diameter — roughly the width of a garden hose — but the CT scan revealed Diane’s had stretched to 5.5 cm.
Doctors told her she needed urgent surgery to strengthen the weakened aorta as there was a real risk it would rupture and she could die.
‘I’d never even heard of an aneurysm before, and I didn’t have any symptoms for it,’ recalls Diane, a widow and retired carer from London.
‘It was picked up purely by chance from having the chest scan, I’d had no symp
Men aged 65 are offered a scan but women are excluded
toms other than the cough — and no pain. I was very scared — I was scared even to sleep in case something happened. I said to the doctor: “Am I going to die?”.’
Diane is one of an estimated 15,000 women and 80,000 men a year in the UK who develop an abdominal aortic aneurysm (AAA) — a ‘silent’ condition with no symptoms.
Smoking, high blood pressure, age and a family history of the condition are the main risk factors, causing the walls of the aorta to weaken and bulge. This worsens over time, making the blood vessel prone to rupture
— if this happens, 80 per cent of patients die. Each year there are around 6,000 deaths caused by the condition in England and Wales.
However, there are huge disparities between men and women in the diagnosis, treatment and outcomes of AAA.
Currently, men are routinely screened for the condition on the NHS, receiving an invitation when they’re 65 for a one-off, five-minute ultrasound scan.
However, the UK National Screening Committee has ruled that routine screening of women is not effective.
So although it can be a medical emergency, AAA is only ever detected in women purely by chance, when a scan for another health issue picks it up.
Indeed, a potentially fatal rupture can be the first time many women become aware of the problem. Yet if detected early, AAA can be repaired, either by open surgery (sewing a graft into the aorta to strengthen it) or by keyhole surgery (inserting a graft via an artery in the groin).
Abdominal aortic aneurysms are not the only example of apparently random exclusions in healthcare due to sex or age-related cut-off points: for instance, people over the age of 74 are excluded from routine NHS lung cancer screening, as are women over 70 from routine breast screening, and you won’t be given the shingles jab if you’re 80 or above.
‘These NHS age limits are very odd,’ TV presenter Dame Esther Rantzen, 83, told Good Health. ‘My GP told me I am slightly too old when I asked to be vaccinated against shingles, in spite of all the adverts telling me how crucial the vaccination is.’
And after being diagnosed with late-stage lung cancer earlier this year, Dame Esther, a former smoker, is also frustrated that over-74s are excluded from the new routine lung cancer screening for former and current smokers.
‘I’m way too old to be screened for lung cancer [as part of this scheme], which is far more common in us oldies, and which was diagnosed in me only when I was 82, and it had already spread and was at stage 4,’ she says.
When it came to diagnosing her AAA, Diane was one of the lucky ones: she was also lucky to be able to have keyhole surgery (which she underwent at St Mary’s Hospital, London, last November, five months after her diagnosis). The operation was a success and she went home a week later.
But many women are disadvantaged at this stage, too — because the criteria for offering operations are based on the anatomy of men’s bodies, not women’s.
A 2017 study in The Lancet, reviewing international research into the condition since 2000, found that although keyhole surgery for AAA has much better outcomes for women — with a 2.1 per cent death rate compared with 6 per cent for open surgery — only a third of women are deemed suitable for it, compared with just over half of men.
This is because women’s arteries are smaller than men’s, so fewer women are eligible because the criteria are based on the size of men’s aortas.
Overall, even though surgery is the only treatment, a third of women are not offered it at all — compared with less than a fifth of men diagnosed with AAA. And death rates in women who do have surgery for AAA are nearly twice those for men — largely due to late diagnosis and also to the fact that women’s smaller arteries can make surgery more difficult.
But now a groundbreaking new £ 2 million study, revealed exclusively to Good Health, could transform the outlook for women with AAA, and potentially lead to routine screening.
Led by Janet Powell, a professor of vascular biology and medicine at Imperial College London, it aims to address the AAA ‘gender gap’ by treating women diagnosed with the condition using revised ‘female-friendly’ definitions.
‘The problem to date is that abdominal aortic aneurysm is still seen as mainly a male condition; as a result, the way we manage the condition — from screening to diagnosis and treatment — has
‘Checks may protect the young and save the NHS, but we grannies have our uses, too’
been developed with men in mind,’ says Professor Powell, who has been researching AAA for almost 40 years, including the 2017 Lancet study.
‘Ninety six per cent of patients involved in clinical trials into AAA are men, and the results of these trials have been applied to women. Yet we know that women’s bodies are generally smaller than men’s, and we believe this means we should be treating women with AAA when the aneurysm is a smaller size than we are doing currently.’
The current medical definition of AAA, for both men and women, is an aorta of 3 cm or wider in diameter. At this width, the patient is monitored; anything over 5.5 cm needs surgery.
The new study will diagnose women (who are picked up by chance on scans) as having AAA if their aorta diameter is 2.5 cm or more. And those whose aorta measures 4 cm to 5.5 cm in diameter, will be offered keyhole surgery or monitoring to discover whether women benefit from early keyhole surgery.
Professor Powell believes these revised definitions ‘could mean the disparities between men and women with AAA are not as great as we currently think. We hope by treating women when they are younger and the aneurysm is smaller, more women will be eligible for keyhole surgery and it will lead to better outcomes and ultimately save lives.’
The trial, called Warriors (Women’s abdominal aortic aneurysm research: repair immediately or routine surveillance), funded by the British Heart Foundation, will involve ten countries.
The 1,200 women participants will be monitored for five years, and their outcomes compared with those of women using the current ‘ male’ definitions. Researchers hope the new definitions will mean women with AAA are treated earlier and with better outcomes — if this is the case, it could make screening of women more cost- effective (because if surgery for women has better outcomes than previously thought, this means it effectively costs less to save a life) so it could be rolled out, a move that is already supported by other experts.
‘Women should be included in the aortic aneurysm screening programmes as smoking [a major risk factor for AAA] has been more prevalent in women, and cardiovascular risk has risen due to more women adopting more “masculine” lifestyles,’ says Duncan Forsyth, a consultant geriatrician at Cambridge University Hospitals NHS Foundation Trust.
This is not the only NHS screening programme that has been called into question for excluding patients.
Earlier this year, the announcement of the first national screening programme for lung cancer attracted criticism for not including over-74s. With an increasingly ageing population — in which the over-70s account for half of cancer cases, a figure that’s also expected to rise — the new programme will offer lung scans to former and current smokers aged 55 to 74 (it will be rolled out across the country by 2028).
It is expected to detect 9,000 cancers annually, saving lives by picking up the disease in the early stages when it is easier to treat (currently, two-thirds of cases are incurable by the time they are detected).
To exclude older people does not make sense, according to Dame Esther Rantzen, who has previously asked: ‘Is it because giving us an extra five or ten years is not considered worth it? If so, I can attest that each day gets more precious with age. Is keeping older people alive too expensive for the NHS?’ Others have pointed out that in the U.S., the upper age limit for lung screening is 80.
Professor David Baldwin, a consultant respiratory physician and clinical adviser on lung cancer screening, says: ‘It’s a difficult call. There will always be some people who are not eligible who, sadly, develop cancer.’
He explains that populationbased research shows a benefit for screening people for lung cancer between the ages of 55 and 74 — but extending it to older age groups would lead to more over diagnosis, the detection of a disease that’s unlikely to cause symptoms or death within their ordinarily expected lifetime. Such patients often die of a cause other than lung cancer.
‘People can also be harmed by having tests and treatment that does not change their life expectancy,’ he says, adding that such limits are ‘ much more difficult’ on an individual level.
‘In a fit and healthy individual aged over 75, screening might be helpful because it could pick up a disease at an early stage when it can be treated, and they could realistically enjoy many more years of life, so it can seem unfair.
‘ It’s a really difficult and complicated issue.’
The UK National Screening Committee says it ‘ makes evidence- based decisions and advises screening at an age where the benefits of screening outweigh the harm it can cause’, but adds that it is ‘receptive’ to any evidence that suggests revising age limits could ‘provide more good than harm’.
Any screening test involves weighing the risks of identifying disease that doesn’t need treatment and the potential harm caused by the treatments themselves against the benefit of early diagnosis when a disease is easier to treat, adds Amy Hirst, health information manager at Cancer Research UK.
‘Before extending the current age limits, we would need to see clearly that the benefits would outweigh the harms and it would reduce cancer deaths,’ she says.
Indeed, this is the focus of new research being carried out on breast cancer screening.
This is currently offered routinely to women aged 50 to 70 every three years on the NHS, but researchers at Oxford University are investigating whether this should be extended to women aged between 47 and 49, and 71 to 73.
The Age X trial, involving more than four million women recruited between 2009 and 2020, offered additional screening to those outside the current limits. They are now being monitored to see whether extra scans make a difference to the number of breast cancer diagnoses, treatment and outcomes compared with those who are not offered extra scans. Results are due in 2026.
Echoing the kinds of concerns raised by Professor Baldwin, Professor Kefah Mokbel, a breast surgeon at the Princess Grace Hospital in London, sounds a word of caution: ‘To date, screening women over 70 is associated with an increased risk of over diagnosis, identifying slowgrowing cancers that may not significantly impact on a woman’s overall life expectancy.
‘Since some women will have a limited remaining lifespan at this age, this makes breast cancer screening less effective.’
But the risk balance is different in women whose life expectancy is greater than ten years, he adds. ‘Therefore, breast cancer screening recommendations should be individualised and tailored based
‘Lung cancer is far more common in us oldies’
Tailoring checks to individuals rather than their age
on other factors they may have that put them at increased risk, breast density [it’s harder to find cancers in denser breasts], and the expected life expectancy for the woman concerned.’
Dr Duncan Forsyth adds: ‘ The problem with increasing longevity is that, unfortunately, we spend a larger part of our lives living with disability, so the potential benefits of interventions does not necessarily rise, whereas the risks involved in treatments/interventions do.’
Since her diagnosis, Diane has been determined to live life to the full. ‘I would never have known I had an AAA if I hadn’t gone for a chest scan for the cough. If the aneurysm had burst, it would have been life or death.’
Thankful for the chances she’s been given, she quit her 20-year, ten-a-day smoking habit: she also takes cholesterol-lowering and blood-thinning medication and has scans of her aorta once a year. ‘I go out with my friends, go for walks and everyone thinks I am much younger than I am,’ she says. ‘I’m doing great.’
‘I know AAA is more common in men, but it does affect women, too, and it doesn’t seem right that whether it is diagnosed in women or not is purely down to chance.’
Adds Esther Rantzen: ‘ Maybe the underlying principle is protect the young and save the NHS by letting the old, who will die soon anyway, catch whatever is around.
‘And to be honest, if they have to choose between screening a parent of young children or an old granny like me, of course I would choose the parent.
‘But if there’s enough screening to go round all of us, I might point out that we grannies have our uses, too.’