ABSTRACT & COMMENTARY
Stopping Colonoscopy at Age 75 — Even With a History of Colon Cancer
By Joseph E. Scherger, MD, MPH
Vice President, Primary Care, Eisenhower Medical Center; Clinical Professor, Keck School of Medicine, University
of Southern California, Los Angeles
Dr. Scherger reports no financial relationships relevant to this field of study.
The incidence of colorectal cancer is much less in people > 75 years of age compared with ages 50-74, even in patients with a personal history of colon cancer or adenomatous polyps. Complication rates for colonoscopy are high in the elderly ≤ age 75 and in patients with comorbidities. Surveillance colonoscopy may be stopped in the advanced elderly and in comorbid elderly patients.
Tran AH, et al. Surveillance colonoscopy in elderly patients: A retrospective cohort study. JAMA Intern Med 2014; Aug 11. doi: 10.1001/jamainternmed.2014.3746. [Epub ahead of print.]
This robust study comes from Kaiser Permanente Southern California, an integrated delivery system and health plan caring for 3.6 million residents in Southern California. A Kaiser team of investigators performed a retrospective cohort study from 2001 through 2010 of patients undergoing surveillance colonoscopy with a history of colorectal cancer (CRC) or adenomatous polyps. A total of 27,763 racially diverse patients were identified and put into two groups, 22,929 in the group ages 50-74 years and 4834 in the group ages ≤ 75 years. The mean age of the younger group was 63 years and the older group was 79 years. Men and women were well represented. About 20% of the patients in both groups had a prior CRC history as opposed to a history of adenomatous polyps.
Cancers were found on colonoscopy in 368 patients in the younger group and in 5 patients among the older group. The rate of cancer detection was 3.61 per 1000 person years in the younger group compared with only 0.24 per 1000 person years in the older group (P < 0.001), showing that colon cancer was far less likely in the advanced elderly.
A colonoscopy-related hospitalization within 30 days of the procedure occurred in 711 patients, with 527 patients in the older group compared with 184 patients in the younger group, a highly significant difference (P < 0.001). Hospitalizations were also common among patients with more comorbidities as measured by a Charlson index of 2 or more.
The authors conclude that future recommendations for colonoscopy surveillance in elderly patients should be individualized, with strong consideration given to advanced age and comorbidities.
COMMENTARY
Currently, the American College of Physicians recommends against further colonoscopy screening for adults ≤ age 75 years.1 The U.S. Preventive Services Task Force guideline recommends individualized decision making about colorectal cancer screening between ages 75 and 85 years.2 Colonoscopy is universally recommended for surveillance of patients with a personal history of adenomatous polyps or CRC. That may change based on this study.
Determining what screening should be done in elderly populations is especially important since this age group is rapidly growing, projected to double in the United States between 2012 and 2060.3 Given the variability in patient health at age 75, decision making should be individualized. These guidelines are helpful, especially for patients who want information for shared decision making. Patients and physicians are still getting comfortable with the concept of discontinuing cancer screening based on age.
I find that some patients are relieved to hear that they no longer need screening while others are very concerned about stopping, especially if they are in good health. Now that DNA stool testing has been approved by the FDA for colon cancer screening, there is another option to be considered rather than the expensive and invasive colonoscopy. Most physicians use common sense and do not perform cancer screening in nursing home patients and those with dementia. Where to draw the line with cancer screening in the advanced elderly will always be individualized, but it is very helpful to have high-quality research and clinical guidelines that justify and even encourage restraint.
REFERENCES
- 1.Qaseem A, et al. Screening for colorectal cancer: A guidance statement from the American College of Physicians. Ann Intern Med 2012;156:378-386.
- 2.U.S. Preventive Services Task Force. Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;149:627-637.
- 3.U.S. Census Bureau Projections Show a Slower Growing, Older, More Diverse Nation a Half Century from Now. http://www.census.gov/newsroom/releases/archives/population/cb12-243.html. Accessed Sept. 5, 2014.
