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Machlab S, Francia E, Mascort J, García-Iglesias P, Mendive JM, Riba F, Guarner-Argente C, Solanes M, Ortiz J, Calvet X. Risks, indications and technical aspects of colonoscopy in elderly or frail patients. Position paper of the Societat Catalana de Digestologia, the Societat Catalana de Geriatria i Gerontologia and the Societat Catalana de Medicina de Familia i Comunitaria. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:107-117. [PMID: 37209916 DOI: 10.1016/j.gastrohep.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 05/01/2023] [Accepted: 05/08/2023] [Indexed: 05/22/2023]
Abstract
Colonoscopy (CS) is an invasive diagnostic and therapeutic technique, allowing the study of the colon. It is a safe and well tolerated procedure. However, CS is associated with an increased risk of adverse events, insufficient preparation and incomplete examinations in the elderly or frail patient (PEA/F). The objective of this position paper was to develop a set of recommendations on risk assessment, indications and special care required for CS in the PEA/F. It was drafted by a group of experts appointed by the SCD, SCGiG and CAMFiC that agreed on eight statements and recommendations, between them to recommend against performing CS in patients with advanced frailty, to indicate CS only if the benefits clearly outweigh the risks in moderate frailty and to avoid repeating CS in patients with a previous normal procedure. We also recommended against performing screening CS in patients with moderate or advanced frailty.
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Affiliation(s)
- Salvador Machlab
- Servei d'Aparell Digestiu, Parc Taulí, Hospital Universitari, Institut de Recerca Parc Taulí, Sabadell, España; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, España
| | - Esther Francia
- Servei de Medicina Interna, Unitat de Geriatria, Hospital de Sant Pau, Barcelona, España
| | - Juanjo Mascort
- CAP Florida Sud, Institut Català de La Salut, Hospitalet de Llobregat, España; Departament de Ciències Clíniques, Facultat de Medicina, Universitat de Barcelona, Barcelona, España
| | - Pilar García-Iglesias
- Servei d'Aparell Digestiu, Parc Taulí, Hospital Universitari, Institut de Recerca Parc Taulí, Sabadell, España
| | | | - Francesc Riba
- Servei de Geriatria i Cures Pal·liatives, Hospital de la Santa Creu Jesús, Tortosa, España
| | - Carles Guarner-Argente
- Servei Aparell Digestiu, Hospital de Sant Pau, Barcelona, España; CIBEREHD, Instituto de Salud Carlos III, Madrid, España
| | - Mònica Solanes
- CAP Onze de Setembre, Institut Català de la Salut, Lleida, España
| | - Jordi Ortiz
- Servei d'Aparell Digestiu, Consorci Sanitari de Terrassa, Terrassa, España
| | - Xavier Calvet
- Servei d'Aparell Digestiu, Parc Taulí, Hospital Universitari, Institut de Recerca Parc Taulí, Sabadell, España; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, España; CIBEREHD, Instituto de Salud Carlos III, Madrid, España.
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Improved Survival in a Cohort of Patients Aged 75 Years and Older With Fecal Immunochemical Testing-Detected Colorectal Cancer. Dis Colon Rectum 2023; 66:511-520. [PMID: 35764093 DOI: 10.1097/dcr.0000000000002409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Fecal immunochemical testing is an accepted form of colorectal cancer screening and is recommended for adults up to the age of 75 years in Canadian guidelines. However, many individuals 75 years and older continue to receive fecal immunochemical testing despite being outside accepted guidelines. OBJECTIVE This study aimed to determine whether patients aged 75 years and older with screen-detected cancer demonstrated improved outcomes and survival compared with patients with non-screen-detected cancer. DESIGN This is a retrospective population-based cohort study. SETTINGS Provincial data were collected from the Alberta Cancer Registry and the Alberta Colorectal Cancer Screening Program between November 2013 and 2019. PATIENTS We identified an aggregated patient cohort aged 75 years and older with a diagnosis of colorectal cancer from November 2013 to November 2019, as well as patients 75 years and older who underwent fecal immunochemical testing within these dates. MAIN OUTCOME MEASURES The proportion of screen-detected colorectal cancers was calculated. Surgical intervention, hospital length of stay, postoperative mortality, and overall survival were analyzed. RESULTS Between November 2013 and 2019, 3586 patients 75 years and older were diagnosed with colorectal cancer; 690 (19%) were "screen-detected." Screen-detected patients were almost 3 times more likely to undergo surgery (OR, 2.83) and had a 36% overall survival benefit (HR, 0.64) compared with non-screen-detected patients, adjusted for other variables such as age, Charlson Comorbidity Index, and stage. LIMITATIONS The retrospective study design prevents conclusions regarding causation. CONCLUSIONS Screen detection of colorectal cancer in patients aged 75 years and older is associated with improved overall survival when controlling for other potential confounders. When compared with their non-screen-detected counterparts, these patients have an earlier stage of disease and are more likely to undergo surgical intervention with improved outcomes, irrespective of age. These data may support screening for appropriately selected patients who would otherwise fall outside of current guidelines. See Video Abstract at http://links.lww.com/DCR/B986 . SOBREVIDA MEJORADA EN UNA COHORTE DE PACIENTES DE AOS O MS CON CNCER COLORRECTAL DETECTADOS POR RIF ANTECEDENTES:La prueba basada en una Reacción Inmunoquímica Fecal - RIF, es una forma aceptada de detección de cáncer colorrectal y esta recomendada en adultos a partir de los 75 años en las guías canadienses. Sin embargo, muchas personas de 75 años o más continúan realizándose pruebas inmunoquímicas fecales a pesar de estar fuera de las guías aceptadas.OBJETIVO:Poder determinar si los pacientes de 75 años o más con detección RIF positiva a un cáncer demuestran mejores resultados y sobrevida comparados con los pacientes sin detección.DISEÑO:Estudio de cohortes retrospectivo basado en una población definida.CONFIGURACIÓN:Se recopilaron los datos provinciales del Registro de cánceres y del Programa de detección de cáncer colorrectal de Alberta, Canada, entre 2013 y 2019.PACIENTES:Identificamos una cohorte agregada de pacientes de 75 años o más con diagnóstico de cáncer colorrectal desde noviembre de 2013 hasta noviembre de 2019, así como pacientes de 75 años o más que se sometieron a pruebas inmunoquímicas fecales dentro de las fechas mencionadas.PRINCIPALES MEDIDAS DE RESULTADO:Se calculó la proporción de cánceres colorrectales detectados mediante un cribado. Se analizaron la intervención quirúrgica, la duración de la estadía hospitalaria, la mortalidad post-operatoria y la sobrevida global.RESULTADOS:Entre noviembre de 2013 y noviembre 2019, 3586 pacientes de 75 años o más, fueron diagnosticados con cáncer colorrectal; 690 (19%) fueron detectados por cribado. Los pacientes detectados mediante el cribado, tenían casi tres veces más probabilidades de someterse a una cirugía (Razón de Probabilidad de 2,83) y beneficiaron de una sobrevida general del 36 % (HR 0,64) comparados con los pacientes sin detectación por cribado, corregidos por otras variables como la edad, el índice de comorbilidad de Charlson y el estadío del tumor.LIMITACIONES:El diseño retrospective del presente estudio impide obtener conclusiones con respecto a la causalidad.CONCLUSIONES:La detección por cribado de cáncer colorrectal en pacientes de 75 años o más se asocia con una mejor sobrevida general cuando se controlan los otros posibles factores de confusión. Comparando con las contrapartes no detectadas por cribado, estos pacientes se encuentran en una etapa más temprana de la enfermedad y es más probable que se sometan a una intervención quirúrgica con mejores resultados, independientemente a la edad. Estos datos pueden respaldar la detección de pacientes adecuadamente seleccionados que, de otro modo, quedarían fuera de las pautas actuales. Consulte Video Resumen en http://links.lww.com/DCR/B986 . (Traducción-Dr. Xavier Delgadillo ).
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Guittet L, Quipourt V, Aparicio T, Carola E, Seitz JF, Paillaud E, Lievre A, Boulahssass R, Vitellius C, Bengrine L, Canoui-Poitrine F, Manfredi S. Should we screen for colorectal cancer in people aged 75 and over? A systematic review - collaborative work of the French geriatric oncology society (SOFOG) and the French federation of digestive oncology (FFCD). BMC Cancer 2023; 23:17. [PMID: 36604640 PMCID: PMC9817257 DOI: 10.1186/s12885-022-10418-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/06/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND We have done a systematic literature review about CRC Screening over 75 years old in order to update knowledge and make recommendations. METHODS PUBMED database was searched in October 2021 for articles published on CRC screening in the elderly, and generated 249 articles. Further searches were made to find articles on the acceptability, efficacy, and harms of screening in this population, together with the state of international guidelines. RESULTS Most benefit-risk data on CRC screening in the over 75 s derived from simulation studies. Most guidelines recommend stopping cancer screening at the age of 75. In private health systems, extension of screening up to 80-85 years is, based on the life expectancy and the history of screening. Screening remains effective in populations without comorbidity given their better life-expectancy. Serious adverse events of colonoscopy increase with age and can outweigh the benefit of screening. The great majority of reviews concluded that screening between 75 and 85 years must be decided case by case. CONCLUSION The current literature does not allow Evidence-Based Medicine propositions for mass screening above 75 years old. As some subjects over 75 years may benefit from CRC screening, we discussed ways to introduce CRC screening in France in the 75-80 age group. IRB: An institutional review board composed of members of the 2 learned societies (SOFOG and FFCD) defined the issues of interest, followed the evolution of the work and reviewed and validated the report.
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Affiliation(s)
- Lydia Guittet
- grid.412043.00000 0001 2186 4076Public Health Unit, CHU Caen NormandieNormandie University, UNICAEN, INSERM U1086 ANTICIPE, Caen, France
| | - Valérie Quipourt
- grid.31151.37Geriatrics Department and Coordination Unit in Oncogeriatry in Burgundy, University Hospital of Dijon, Dijon, France
| | - Thomas Aparicio
- Department of Gastroenterology and Digestive Oncology, Saint Louis Hospital, APHP, Université de Paris, Paris, France
| | - Elisabeth Carola
- grid.418090.40000 0004 1772 4275Geriatric Oncology Unit, Groupe Hospitalier Public du Sud de L’Oise, Bd Laennec, 60100 Creil, France
| | - Jean-François Seitz
- grid.411266.60000 0001 0404 1115Department of Digestive Oncology & Gastroenterology, CHU Timone, Assistance Publique-Hôpitaux de Marseille (APHM) & Aix-Marseille-Univ, Marseille, France
| | - Elena Paillaud
- grid.414093.b0000 0001 2183 5849Geriatric Oncology Unit, Georges Pompidou European Hospital, Paris Cancer Institute CARPEM, inAP-HP, Paris, France
| | - Astrid Lievre
- grid.414271.5Department of Gastroenterology, INSERM U1242 “Chemistry Oncogenesis Stress Signaling”, University Hospital Pontchaillou, Rennes 1 University, Rennes, FFCD France
| | - Rabia Boulahssass
- grid.410528.a0000 0001 2322 4179Geriatric Coordination Unit for Geriatric Oncology (UCOG), PACA Est CHU de NICE, France; FHU ONCOAGE, Nice, France
| | - Carole Vitellius
- grid.411147.60000 0004 0472 0283Hepato-Gastroenterology Department, Angers University Hospital, Angers, France ,grid.7252.20000 0001 2248 3363HIFIH Laboratory UPRES EA3859, Angers University, SFR 4208, Angers, France
| | - Leila Bengrine
- Department of Medical Oncology, Georges-Francois Leclerc Centre, Dijon, France
| | - Florence Canoui-Poitrine
- grid.412116.10000 0004 1799 3934Public Health Unit, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, 94000 Créteil, France
| | - Sylvain Manfredi
- grid.31151.37Gastroenterology and Digestive Oncology Unit, University Hospital Dijon, INSERM U123-1 University of Bourgogne-Franche-Comté, FFCD (French Federation of Digestive Cancer), Dijon, France
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Dalton AF, Golin CE, Morris C, Kistler CE, Dolor RJ, Bertin KB, Suresh K, Patel SG, Lewis CL. Effect of a Patient Decision Aid on Preferences for Colorectal Cancer Screening Among Older Adults: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2244982. [PMID: 36469317 PMCID: PMC9855297 DOI: 10.1001/jamanetworkopen.2022.44982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Guidelines recommend individualized decision-making for colorectal cancer (CRC) screening among adults aged 76 to 84 years, a process that includes a consideration of health state and patient preference. OBJECTIVE To determine whether a targeted patient decision aid would align older adults' screening preference with their potential to benefit from CRC screening. DESIGN, SETTING, AND PARTICIPANTS This is a prespecified secondary analysis from a randomized clinical trial. Participants aged 70 to 84 years who were not up to date with screening and had an appointment within 6 weeks were purposively sampled by health state (poor, intermediate, or good) at 14 community-based primary care practices and block randomized to receive the intervention or control. Patients were recruited from March 1, 2012, to February 28, 2015, and these secondary analyses were performed from January 15 to March 1, 2022. INTERVENTIONS Patient decision aid targeted to age and sex. MAIN OUTCOMES AND MEASURES The primary outcome of this analysis was patient preference for CRC screening. The a priori hypothesis was that the decision aid (intervention) group would reduce the proportion preferring screening among those in poor and intermediate health compared with the control group. RESULTS Among the 424 participants, the mean (SD) age was 76.8 (4.2) years; 248 (58.5%) of participants were women; and 333 (78.5%) were White. The proportion preferring screening in the intervention group was less than in the control group for those in the intermediate health state (34 of 76 [44.7%] vs 40 of 73 [54.8%]; absolute difference, -10.1% [95% CI, -26.0% to 5.9%]) and in the poor health state (24 of 62 [38.7%] vs 33 of 61 [54.1%]; absolute difference, -15.4% [95% CI, -32.8% to 2.0%]). These differences were not statistically significant. The proportion of those in good health who preferred screening was similar between the intervention and control groups (44 of 74 [59.5%] for intervention vs 46 of 75 [61.3%] for control; absolute difference, -1.9% [95% CI, -17.6% to 13.8%]). CONCLUSIONS AND RELEVANCE The findings of this secondary analysis of a clinical trial did not demonstrate statistically significant differences in patient preferences between the health groups. Additional studies that are appropriately powered are needed to determine the effect of the decision aid on the preferences of older patients for CRC screening by health state. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01575990.
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Affiliation(s)
- Alexandra F. Dalton
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Carol E. Golin
- Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill
- Division of General Internal Medicine and Clinical Epidemiology, Department of Medicine, The University of North Carolina at Chapel Hill
- Gillings School of Global Public Health, Department of Health Behavior, The University of North Carolina at Chapel Hill
| | - Carolyn Morris
- Division of Data Sciences Safety and Regulatory, Division of Biostatistics, Department of Research & Development Solutions, IQVIA, Durham, North Carolina
| | - Christine E. Kistler
- Department of Family Medicine, School of Medicine, The University of North Carolina at Chapel Hill
| | - Rowena J. Dolor
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Kaitlyn B. Bertin
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora
| | - Krithika Suresh
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora
| | - Swati G. Patel
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
| | - Carmen L. Lewis
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
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Shen C, Kwon M, Moss JL, Schaefer E, Zhou S, Dodge D, Ruffin MT. Utilization of Mammography During the Last Year of Life Among Older Breast Cancer Survivors. J Womens Health (Larchmt) 2022; 31:941-948. [PMID: 35394350 DOI: 10.1089/jwh.2021.0517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Mammography is generally recommended for breast cancer survivors. However, discussion is ongoing about stopping surveillance mammography when life expectancy is <5-10 years as the benefit of screening might be diminished toward the end of life. The utilization pattern of mammography in the last year of life among this population has not been well studied. Methods: We identified 58,736 females diagnosed with breast cancer between January 2002 and December 2015, who died at the age of at least 67, from the SEER-Medicare database. We examined the utilization patterns of mammography during their last year of life and investigated factors associated with the use of mammography at the end of life using a multivariable logistic regression model. Results: Overall, 28.5% of the patients received mammography during the last year of life. Multivariable logistic regression showed that older age (OR = 0.31, 95% CI = 0.29-0.34, p < 0.001 for 95 vs. 85 years old), more advanced cancer stage (OR = 0.22, 95% CI = 0.20-0.24 p < 0.001 for distant vs. localized disease), and higher comorbidity score (OR = 0.92, 95% CI = 0.91-0.93, p < 0.001 for every 1-point increase) were associated with less mammography use. Age was nonlinearly associated with mammography use, with a steady proportion of patients receiving a mammography until approximately age 80 and then a sharp decrease thereafter. Conclusion: This population-based study found that a sizable proportion of older breast cancer survivors received mammography during the last year of life.
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Affiliation(s)
- Chan Shen
- Department of Surgery and College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Michelle Kwon
- College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Jennifer L Moss
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
- Department of Family and Community Medicine, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Eric Schaefer
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Shouhao Zhou
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Daleela Dodge
- Department of Surgery and College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Mack T Ruffin
- Department of Family and Community Medicine, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
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Colonoscopy-Related Adverse Events in Patients With Abnormal Stool-Based Tests: A Systematic Review of Literature and Meta-analysis of Outcomes. Am J Gastroenterol 2022; 117:381-393. [PMID: 35029161 DOI: 10.14309/ajg.0000000000001614] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 12/27/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Colorectal cancer (CRC) screening programs based on the fecal immunochemical test (FIT) and guaiac-based fecal occult blood (gFOBT) are associated with a substantial reduction in CRC incidence and mortality. We conducted a systematic review and comprehensive meta-analysis to evaluate colonoscopy-related adverse events in individuals with a positive FIT or gFOBT. METHODS A systematic and detailed search was run in January 2021, with the assistance of a medical librarian for studies reporting on colonoscopy-related adverse events as part of organized CRC screening programs. Meta-analysis was performed using the random-effects model, and the results were expressed for pooled proportions along with relevant 95% confidence intervals (CIs). RESULTS A total of 771,730 colonoscopies were performed in patients undergoing CRC screening using either gFOBT or FIT across 31 studies. The overall pooled incidence of severe adverse events in the entire patient cohort was 0.42% (CI 0.20-0.64); I2 = 38.76%. In patients with abnormal gFOBT, the incidence was 0.2% (CI 0.1-0.3); I2 = 24.6%, and in patients with a positive FIT, it was 0.4% (CI 0.2-0.7); I2 = 48.89%. The overall pooled incidence of perforation, bleeding, and death was 0.13% (CI 0.09-0.21); I2 = 22.84%, 0.3% (CI 0.2-0.4); I2 = 35.58%, and 0.01% (CI 0.00-0.01); I2 = 33.21%, respectively. DISCUSSION Our analysis shows that in colonoscopies performed after abnormal stool-based testing, the overall risk of severe adverse events, perforation, bleeding, and death is minimal.
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Emile SH, Barsom SH, Wexner SD. An updated review of the methods, guidelines of, and controversies on screening for colorectal cancer. Am J Surg 2022; 224:339-347. [DOI: 10.1016/j.amjsurg.2022.03.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/15/2022] [Accepted: 03/23/2022] [Indexed: 02/06/2023]
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Chaput G, Del Giudice ME, Kucharski E. Dépistage du cancer au Canada. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2021; 67:e12-e14. [PMID: 33483408 PMCID: PMC7822604 DOI: 10.46747/cfp.6701e12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Geneviève Chaput
- Médecin traitante aux départements de médecine de famille, de soins secondaires et d'oncologie au Centre universitaire de santé McGill et à l'Université McGill à Montréal (Québec), elle est également directrice médicale intérimaire à la Maison de soins palliatifs de Vaudreuil-Soulanges à Hudson (Québec)
| | - M Elisabeth Del Giudice
- Médecin de famille à la Sunnybrook Academic Family Health Team, professeure adjointe au département de médecine familiale et communautaire de l'Université de Toronto (Ontario) et elle est responsable du programme régional de dépistage du cancer en première ligne de Toronto Central North à Santé Ontario-Action Cancer Ontario
| | - Ed Kucharski
- Médecin de famille dans l'équipe de santé familiale South East Toronto de l'Université de Toronto, et il est responsable du programme régional de dépistage du cancer en première ligne à Santé Ontario-Action Cancer Ontario
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Chaput G, Del Giudice ME, Kucharski E. Cancer screening in Canada: What's in, what's out, what's coming. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2021; 67:27-29. [PMID: 33483392 PMCID: PMC7822600 DOI: 10.46747/cfp.670127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Genevieve Chaput
- Attending physician in the Departments of Family Medicine, Secondary Care and Oncology at McGill University Health Centre and McGill University in Montreal, Que, and Interim Medical Director of Maison de soins palliatifs de Vaudreuil-Soulanges in Hudson, Que
| | - M Elisabeth Del Giudice
- A family physician with the Sunnybrook Academic Family Health Team, Assistant Professor in the Department of Family and Community Medicine at the University of Toronto in Ontario, and Regional Primary Care Cancer Screening Lead in Toronto Central North at Ontario Health-Cancer Care Ontario
| | - Ed Kucharski
- Family physician with the South East Toronto Family Health Team at the University of Toronto, and Regional Primary Care Cancer Screening Lead at Ontario Health-Cancer Care Ontario
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Rubenstein JH, Noureldin M, Tavakkoli A, Hur C, Omidvari AH, Waljee AK. Utilization of Surveillance Endoscopy for Barrett's Esophagus in Medicare Enrollees. Gastroenterology 2020; 158:773-775.e1. [PMID: 31676263 PMCID: PMC8576742 DOI: 10.1053/j.gastro.2019.10.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 10/15/2019] [Accepted: 10/23/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Joel H. Rubenstein
- Center for Clinical Management Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan,Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan,lnstitute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan,Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Mohamed Noureldin
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Anna Tavakkoli
- Division of Gastroenterology, University of Texas Southwestern, Dallas, Texas
| | - Chin Hur
- Department of Medicine, Columbia University Medical Center, New York, New York
| | | | - Akbar K. Waljee
- Center for Clinical Management Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan,Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan,lnstitute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
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Maratt JK, Calderwood AH. Colorectal Cancer Screening and Surveillance Colonoscopy in Older Adults. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2019; 17:292-302. [PMID: 30969399 PMCID: PMC6584566 DOI: 10.1007/s11938-019-00230-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW The purpose of this chapter is to highlight current recommendations regarding colorectal cancer (CRC) screening and post-polypectomy surveillance colonoscopy in older adults and to review the available literature in order to help inform decision-making in this age group. RECENT FINDINGS Age is a risk factor for CRC; however, older adults with a history of prior screening are at lower risk for CRC compared to those who have never been screened. Decision-making for CRC screening and post-polypectomy surveillance colonoscopy in older adults is complex and several factors including age, screening history, comorbidities, functional status, bowel preparation, prior experiences, preferences, and barriers need to be considered when weighing risks and benefits. Recent guidelines have started to incorporate life expectancy and prior screening history into their recommendations; however, how to incorporate these factors into actual clinical practice is less clear. There are limited data on the relative benefits of screening and surveillance in older adults and therefore, at this time, decision-making should be individualized and incorporate patient preferences in addition to medical factors.
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Affiliation(s)
- Jennifer K Maratt
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Audrey H Calderwood
- Section of Gastroenterology, Department of Medicine, Dartmouth Geisel School of Medicine and the Dartmouth Institute for Health Policy and Clinical Practice, One Medical Center Drive, Lebanon, NH, 03756, USA.
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Schoenborn NL, Huang J, Sheehan OC, Wolff JL, Roth DL, Boyd CM. Influence of Age, Health, and Function on Cancer Screening in Older Adults with Limited Life Expectancy. J Gen Intern Med 2019; 34:110-117. [PMID: 30402822 PMCID: PMC6318172 DOI: 10.1007/s11606-018-4717-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 09/11/2018] [Accepted: 09/11/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND/OBJECTIVES We examined the relationship between cancer screening and life expectancy predictors, focusing on the influence of age versus health and function, in older adults with limited life expectancy. DESIGN Longitudinal cohort study SETTING: National Health and Aging Trends Study (NHATS) with linked Medicare claims. PARTICIPANTS Three cohorts of adults 65+ enrolled in fee-for-service Medicare were constructed: women eligible for breast cancer screening (n = 2043); men eligible for prostate cancer screening (n = 1287); men and women eligible for colorectal cancer screening (n = 3759). MEASUREMENTS We assessed 10-year mortality risk using 2011 NHATS data, then used claims data to assess 2-year prostate and breast cancer screening rates and 3-year colorectal cancer screening rates. Among those with limited life expectancy (10-year mortality risk > 50%), we stratified participants at each level of predicted mortality risk and split participants in each risk stratum by the median age. We assembled two sub-groups from these strata that were matched on predicted life expectancy: a "younger sub-group" with relatively poorer health/functional status and an "older sub-group" with relatively better health/functional status. We compared screening rates between sub-groups. RESULTS For all three cancer screenings, the younger sub-groups (average ages 73.4-76.1) had higher screening rates than the older sub-groups (average ages 83.6-86.9); screening rates were 42.9% versus 34.2% for prostate cancer screening (p = 0.02), 33.6% versus 20.6% for breast cancer screening (p < 0.001), 13.1% versus 6.7% for colorectal cancer screening in women (p = 0.006), and 20.5% versus 12.1% for colorectal cancer screening in men (p = 0.002). CONCLUSION Among older adults with limited life expectancy, those who are relatively younger with poorer health and functional status are over-screened for cancer at higher rates than those who are older with the same predicted life expectancy.
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Affiliation(s)
- Nancy L Schoenborn
- The Johns Hopkins School of Medicine, Baltimore, MD, USA. .,The Johns Hopkins Center on Aging and Health, Baltimore, MD, USA.
| | - Jin Huang
- The Johns Hopkins School of Medicine, Baltimore, MD, USA.,The Johns Hopkins Center on Aging and Health, Baltimore, MD, USA
| | - Orla C Sheehan
- The Johns Hopkins School of Medicine, Baltimore, MD, USA.,The Johns Hopkins Center on Aging and Health, Baltimore, MD, USA
| | - Jennifer L Wolff
- The Johns Hopkins Center on Aging and Health, Baltimore, MD, USA.,The Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - David L Roth
- The Johns Hopkins School of Medicine, Baltimore, MD, USA.,The Johns Hopkins Center on Aging and Health, Baltimore, MD, USA
| | - Cynthia M Boyd
- The Johns Hopkins School of Medicine, Baltimore, MD, USA.,The Johns Hopkins Center on Aging and Health, Baltimore, MD, USA
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Isohata N, Shimojima R, Utano K, Nemoto D, Endo S, Kato H, Takayanagi D, Aizawa M, Nemoto T, Kawarai Lefor A, Togashi K. Colonoscopy in Patients Aged 85 Years or Older: An Observational Study. J Anus Rectum Colon 2018; 2:155-161. [PMID: 31559358 PMCID: PMC6752140 DOI: 10.23922/jarc.2018-014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 07/17/2018] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Colonoscopy is the first-line modality to examine the colon even in the very elderly but may have an increased risk of complications. This study aimed to evaluate the efficacy and safety of colonoscopy in the very elderly. METHODS Patients ≥85y old, who underwent colonoscopy between September 2010 and August 2012 in two tertiary-care hospitals in Japan were enrolled. Main outcome measures were cecal intubation rate, detection rate of adenomas and cancers, treatment, adverse events, and long-term outcomes. RESULTS A total of 207 colonoscopies were performed in 177 patients (females 72, males 105; maximum age 95 years). Of these, 202 attempted to reach the cecum, with success in 92%. Excluding patients with known colorectal neoplasms, invasive cancers were detected in 12%, including T1 lesions in 2% and T2 or deeper in 9%. No cancers were detected in patients referred for surveillance or mild abdominal symptoms. Cancers were found in 25% of patients with positive fecal immunochemical tests, 22% with altered bowel habits, 21% with anemia, and 18% with hematochezia. Treatment of 29 patients with cancer included surgery in 22, endoscopic resection in two and no treatment (due to comorbidities) in five. There were no complications. During 730 days (mean) of follow up, 27 patients died but only three died from recurrent colorectal cancer. CONCLUSIONS Colonoscopy for patients aged ≥85 years is safe. A relatively high detection rate of cancers was found, and most were treatable and even curable. (UMIN000018575).
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Affiliation(s)
- Noriyuki Isohata
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University, Fukushima, Japan
| | - Rieko Shimojima
- Department of Endoscopy, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Kenichi Utano
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University, Fukushima, Japan
| | - Daiki Nemoto
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University, Fukushima, Japan
| | - Shungo Endo
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University, Fukushima, Japan
| | - Hiroyuki Kato
- Department of Endoscopy, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Daisuke Takayanagi
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University, Fukushima, Japan
| | - Masato Aizawa
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University, Fukushima, Japan
| | - Tetsutaro Nemoto
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University, Fukushima, Japan
| | | | - Kazutomo Togashi
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University, Fukushima, Japan
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14
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Kistler CE, Vu M, Sutkowi-Hemstreet A, Gizlice Z, Harris RP, Brewer NT, Lewis CL, Dolor RJ, Barclay C, Sheridan SL. Exploring factors that might influence primary-care provider discussion of and recommendation for prostate and colon cancer screening. Int J Gen Med 2018; 11:179-190. [PMID: 29844698 PMCID: PMC5962312 DOI: 10.2147/ijgm.s153887] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Primary-care providers may contribute to the use of low-value cancer screening. Objective We sought to examine circumstances under which primary-care providers would discuss and recommend two types of cancer screening services across a spectrum of net benefit and other factors known to influence screening. Patients and methods This was a cross sectional survey of 126 primary-care providers in 24 primary-care clinics in the US. Participants completed surveys with two hypothetical screening scenarios for prostate or colorectal cancer (CRC). Patients in the scenarios varied by age and screening-request status. For each scenario, providers indicated whether they would discuss and recommend screening. Providers also reported on their screening attitudes and the influence of other factors known to affect screening (short patient visits, worry about lawsuits, clinical reminders/performance measures, and screening guidelines). We examined associations between providers’ attitudes and their screening recommendations for hypothetical 90-year-olds (the lowest-value screening). Results Providers reported they would discuss cancer screening more often than they would recommend it (P<0.001). More providers would discuss and recommend screening for CRC than prostate cancer (P<0.001), for younger than older patients (P<0.001), and when the patient requested it than when not (P<0.001). For a 90-year-old patient, every point increase in cancer-specific screening attitude increased the likelihood of a screening recommendation (30% for prostate cancer and 30% for CRC). Discussion While most providers’ reported practice patterns aligned with net benefit, some providers would discuss and recommend low-value cancer screening, particularly when faced with a patient request. Conclusion More work appears to be needed to help providers to discuss and recommend screening that aligns with value.
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Affiliation(s)
| | - Maihan Vu
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Ziya Gizlice
- Biostatistical Support Unit, Center for Health Promotion and Disease Prevention
| | | | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Carmen L Lewis
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Rowena J Dolor
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC
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15
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Lewis CL, Kistler CE, Dalton AF, Morris C, Ferrari R, Barclay C, Brewer NT, Dolor R, Harris R, Vu M, Golin CE. A Decision Aid to Promote Appropriate Colorectal Cancer Screening among Older Adults: A Randomized Controlled Trial. Med Decis Making 2018; 38:614-624. [DOI: 10.1177/0272989x18773713] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background. Concerns have been raised about both over- and underutilization of colorectal cancer (CRC) screening in older patients and the need to align screening behavior with likelihood of net benefit. Objective. The purpose of this study was to test a novel use of a patient decision aid (PtDA) to promote appropriate CRC screening in older adults. Methods. A total of 424 patients ages 70 to 84 y who were not up to date with CRC screening participated in a double-blinded randomized controlled trial of a PtDA targeted to older adults making decisions about whether to undergo CRC screening from March 2012 to February 2015. Intervention. Patients were randomized to a targeted PtDA or an attention control. The PtDA was designed to facilitate individualized decision making—helping patients understand the potential risks, benefits, and uncertainties of CRC screening given advanced age, health state, preferences, and values. Outcomes. Two composite outcomes, appropriate CRC screening behavior 6 mo after the index visit and appropriate screening intent immediately after the visit, were defined as completed screening or intent for patients in good health, discussion about screening with their provider for patients in intermediate health, and no screening or intent for patients in poor health. Health state was determined by age and Charlson Comorbidity Index. Results. Four hundred twelve (97%) and 421 (99%) patients were analyzed for the primary and secondary outcomes, respectively. Appropriate screening behavior at 6 mo was higher in the intervention group (55% v. 45%, P = 0.023) as was appropriate screening intent following the provider visit (61% v. 47%, P = 0.003). Limitations. The study took place in a single geographic region. The appropriate CRC screening classification system used in this study has not been formally validated. Conclusions. A PtDA for older adults promoted appropriate CRC screening behavior and intent. Trial Registration: Clinicaltrials.gov, registration number NCT01575990. https://clinicaltrials.gov/ct2/show/NCT01575990?term=epic-d&rank=1
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Affiliation(s)
- Carmen L. Lewis
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Christine E. Kistler
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alexandra F. Dalton
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Carolyn Morris
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Renée Ferrari
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Colleen Barclay
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Noel T. Brewer
- Department of Health Behavior, Gillings School of Global Health, and Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rowena Dolor
- Division of General Internal Medicine, Department of Medicine, Duke School of Medicine, Durham, NC, USA
| | - Russell Harris
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maihan Vu
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carol E. Golin
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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16
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Kistler CE, Golin C, Morris C, Dalton AF, Harris RP, Dolor R, Ferrari RM, Brewer NT, Lewis CL. Design of a randomized clinical trial of a colorectal cancer screening decision aid to promote appropriate screening in community-dwelling older adults. Clin Trials 2017; 14:648-658. [PMID: 29025270 DOI: 10.1177/1740774517725289] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Appropriate colorectal cancer screening in older adults should be aligned with the likelihood of net benefit. In general, patient decision aids improve knowledge and values clarity, but in older adults, they may also help patients identify their individual likelihood of benefit and foster individualized decision-making. We report on the design of a randomized clinical trial to understand the effects of a patient decision aid on appropriate colorectal cancer screening. This report includes a description of the baseline characteristics of participants. METHODS English-speaking primary care patients aged 70-84 years who were not currently up to date with screening were recruited into a randomized clinical trial comparing a tailored colorectal cancer screening decision aid with an attention control. The intervention group received a decision aid that included a values clarification exercise and individualized decision-making worksheet, while the control group received an educational pamphlet on safe driving behaviors. The primary outcome was appropriate screening at 6 months based on chart review. We used a composite measure to define appropriate screening as screening for participants in good health, a discussion about screening for patients in intermediate health, and no screening for patients in poor health. Health state was objectively determined using patients' Charlson Comorbidity Index score and age. RESULTS A total of 14 practices in central North Carolina participated as part of a practice-based research network. In total, 424 patients were recruited to participate and completed a baseline visit. Overall, 79% of participants were White and 58% female, with a mean age of 76.8 years. Patient characteristics between groups were similar by age, gender, race, education, insurance coverage, or work status. Overall, 70% had some college education or more, 57% were married, and virtually all had Medicare insurance (90%). The three primary medical conditions among the cohort were a history of diabetes, pneumonia, and cancer (28%, 26%, and 21%, respectively). CONCLUSION We designed a randomized clinical trial to test a novel use of a patient decision aid to promote appropriate colorectal cancer screening and have recruited a diverse study population that seems similar between the intervention and control groups. The study should be able to determine the ability of a patient decision aid to increase individualized and appropriate colorectal cancer screening.
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Affiliation(s)
- Christine E Kistler
- 1 Department of Family Medicine, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,2 UNC Lineberger Comprehensive Cancer Center, Departments of Medicine and Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,3 Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carol Golin
- 3 Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,4 Departments of Medicine and Health Behavior, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carolyn Morris
- 5 Center for Gastrointestinal Biology and Disease, Department of Medicine, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alexandra F Dalton
- 6 Division of General Internal Medicine, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Russell P Harris
- 2 UNC Lineberger Comprehensive Cancer Center, Departments of Medicine and Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,3 Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rowena Dolor
- 7 Duke Clinical Research Institute, Department of Medicine, School of Medicine, Duke University, Durham, NC, USA
| | - Renée M Ferrari
- 3 Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Noel T Brewer
- 3 Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,8 Department of Health Behavior, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,9 Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carmen L Lewis
- 6 Division of General Internal Medicine, School of Medicine, University of Colorado, Aurora, CO, USA
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17
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Kistler CE, Zimmerman S, Ward KT, Reed D, Golin C, Lewis CL. Health of Older Adults in Assisted Living and Implications for Preventive Care. THE GERONTOLOGIST 2017; 57:949-954. [PMID: 27053505 DOI: 10.1093/geront/gnw053] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 01/20/2016] [Indexed: 12/18/2022] Open
Abstract
Purpose of the Study Older adults in residential care and assisted living (RC/AL) are less healthy than the general elderly population, and some have needs similar to those in nursing homes, making this an important group in which to assess potential overuse or underuse of preventive services. We determined the health status of RC/AL residents and distinguished characteristics between those who may and may not benefit from preventive services requiring a life expectancy ≥5 years. Design and Methods Cross-sectional survey of a nationally representative sample of RC/AL residents using 2010 data from the National Survey of Residential Care Facilities. The primary outcome was the weighted frequency distribution of health states using three predictive mortality indices: Charlson Comorbidity Index, 4-year mortality index, and 9-year mortality index. Results A total of 666,700 of 733,300 (weighted) residents met criteria for inclusion. Based on the three indices, 10%-15% were in good health, 11%-70% in intermediate health, and 20%-76% in poor health. Implications Using triangulation between 3 well-validated mortality indices, 10%-15% of RC/AL residents are in good health and highly likely to benefit from preventive services that require ≥5 year life expectancy. In addition, many residents have uncertain benefit and would benefit from shared decision making.
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Affiliation(s)
- Christine E Kistler
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill.,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.,School of Social Work, University of North Carolina at Chapel Hill
| | - Kimberly T Ward
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - David Reed
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Carol Golin
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.,Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill
| | - Carmen L Lewis
- Department of Medicine, School of Medicine, University of Colorado, Denver
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18
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Magrath M, Yang E, Singal AG. Personalizing Colon Cancer Screening: Role of Age and Comorbid Conditions. CURRENT COLORECTAL CANCER REPORTS 2017. [DOI: 10.1007/s11888-017-0367-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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19
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Colorectal cancer screening: Systematic review of screen-related morbidity and mortality. Cancer Treat Rev 2017; 54:87-98. [DOI: 10.1016/j.ctrv.2017.02.002] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 02/02/2017] [Accepted: 02/03/2017] [Indexed: 12/12/2022]
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20
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Chen CH, Wen CP, Tsai MK. Fecal immunochemical test for colorectal cancer from a prospective cohort with 513,283 individuals: Providing detailed number needed to scope (NNS) before colonoscopy. Medicine (Baltimore) 2016; 95:e4414. [PMID: 27603337 PMCID: PMC5023859 DOI: 10.1097/md.0000000000004414] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The fecal immunochemical test (FIT) is underutilized, in part, because its benefits have not been fully understood. We assessed the relationship of FIT values with cancer incidence and mortality, and explored how repeated administrations of FIT could aid clinicians. A cohort with 513,283 adults in Taiwan participated in a screening program between 1994 and the end of 2007. Colorectal cancer was identified from National Cancer Registry and not from colonoscopy. Positive FIT was FIT ≥ 100 ng/mL. Number needed to scope (NNS) to identify 1 cancer by different FIT values was calculated for the study time. Only 4% of subjects had FIT ≥ 100 ng/mL but contributed 40% of cancer cases, leading to a NNS of 25 for finding 1 in this group. However, within the same FIT ≥ 100 ng/mL, NNS was different by age: 10 for age 60 to 69 years, 42 for age 40 to 49 years, and 156 for age 20 to 39 years. Furthermore, within the same age, NNS was different by FIT values, for instance, 66 for FIT 100 to 199 ng/mL and 12 for FIT 600 to 799 ng/mL, a difference of 5-fold for age 50 to 59 years. The dose-response relationship of FIT can facilitate consultation regarding the need for colonoscopy by providing a quantitative NNS for cancer risk, an index easily understood by patients. Our conclusion made use of (a) age-dependent and (b) quantitative interpretation of FIT values. This single cutpoint practice obliterates a large amount of valuable cancer risk information available to patients.
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Affiliation(s)
- Chien Hua Chen
- Digestive Disease Center, Show-Chwan Memorial Hospital, Changhua
- Chung Chou University of Science and Technology, Changhua
- Hungkuang University, Taichung
| | - Chi Pang Wen
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan
- China Medical University, Taichung, Taiwan
- Correspondence: Chi Pang Wen, China Medical University Hospital, 91 Hsueh-Shih Road Taichung 40402, Taiwan and Institute of Population Health Sciences, National Health Research Institutes, 35 Keyan Road, Zhunan Town, Miaoli County 35053, Taiwan (e-mail: )
| | - Min Kuang Tsai
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan
- China Medical University, Taichung, Taiwan
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21
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Diagnostic colonoscopy following a positive fecal occult blood test in community health center patients. Cancer Causes Control 2016; 27:881-7. [PMID: 27228991 DOI: 10.1007/s10552-016-0763-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 05/13/2016] [Indexed: 01/07/2023]
Abstract
PURPOSE Fecal occult blood testing (FOBT) is a pragmatic screening option for many community health centers (CHCs), but FOBT screening programs will not reduce mortality if patients with positive results do not undergo diagnostic colonoscopy (DC). This study was conducted to investigate DC completion among CHC patients. METHODS This retrospective cohort study used data from three CHCs in the Midwest and Southwest. The primary study outcome was DC completion within 6 months of positive FOBT among adults age 50-75. Patient data was collected using automated electronic queries. Manual chart reviews were conducted if queries produced no evidence of DC. Poisson regression models described adjusted relative risks (RRs) of DC completion. RESULTS The study included 308 patients; 63.3 % were female, 48.7 % were Spanish speakers and 35.7 % were uninsured. Based on combined query and chart review findings, 51.5 % completed DC. Spanish speakers were more likely than English speakers to complete DC [RR 1.19; 95 % confidence interval (CI) 1.04-1.36; P = 0.009], and DC completion was lower among patients with 0 visits than those with 1-2 visits (RR 2.81; 95% CI 1.83-4.33; P < 0.001) or ≥3 visits (RR 3.06; 95% CI 1.57-5.95; P = 0.001). CONCLUSIONS DC completion was low overall, which raises concerns about whether FOBT can reduce CRC mortality in practice. Further research is needed to understand whether CHC navigator programs can achieve very high DC rates. If organizations use FOBT as their primary CRC screening approach and a substantial number of patients receive positive results, both screening rates and DC rates should be measured.
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22
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Morland TB, Synnestvedt M, Honeywell S, Yang F, Armstrong K, Guerra C. Effect of a Financial Incentive for Colorectal Cancer Screening Adherence on the Appropriateness of Colonoscopy Orders. Am J Med Qual 2016; 32:292-298. [PMID: 27259869 DOI: 10.1177/1062860616646848] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Performance incentives for preventive care may encourage inappropriate testing, such as cancer screening for patients with short life expectancies. Defining screening colonoscopies for patients with a >50% 4-year mortality risk as inappropriate, the authors performed a pre-post analysis assessing the effect of introducing a cancer screening incentive on the proportion of screening colonoscopy orders that were inappropriate. Among 2078 orders placed by 23 attending physicians in 4 academic general internal medicine practices, only 0.6% (n = 6/1057) of screening colonoscopy orders in the preintervention period and 0.6% (n = 6/1021) of screening colonoscopy orders in the postintervention period were deemed "inappropriate." This study found no evidence that the incentive led to an increase in inappropriate screening colonoscopy orders.
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Affiliation(s)
| | | | | | - Feifei Yang
- 2 University of Pennsylvania Health System, Philadelphia, PA
| | | | - Carmen Guerra
- 2 University of Pennsylvania Health System, Philadelphia, PA
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Pollack CE, Blackford AL, Schoenborn NL, Boyd CM, Peairs KS, DuGoff EH. Comparing Prognostic Tools for Cancer Screening: Considerations for Clinical Practice and Performance Assessment. J Am Geriatr Soc 2016; 64:1032-8. [PMID: 27131231 DOI: 10.1111/jgs.14089] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To compare the agreement and rates of cancer screening using four prognostic tools that require different types of clinical information. DESIGN Observational retrospective cohort study. SETTING 2009 and 2010 waves of the Medicare Current Beneficiary Survey. PARTICIPANTS Adults aged 66-90 with survey and claims data (N = 9,469). MEASUREMENTS Agreement between four indices predicting short-term (4-5 years) and long-term (9-10 years) survival; self-reported breast and prostate cancer screening. RESULTS Agreement between the four prognostic tools was high. Pearson correlation coefficients ranged from 0.63 to 0.90 for short-term survival and 0.68 to 0.94 for long-term survival. When defining limited short-term life expectancy as less than 25% chance of surviving 4 or 5 years, all four tools agreed in 96.4% of the sample. All four tools agreed in their placement of participants into limited or not-limited long-term life expectancy in 77.1% of participants (<25% chance of surviving 9 or 10 years). Rates of cancer screening were similarly high in individuals with limited long-term life expectancy regardless of the tool used: greater than 31% for mammographic screening in women and greater than 69% for prostate cancer screening. CONCLUSION There is substantial agreement among different prognostic tools for short- and long-term survival in Medicare beneficiaries. The high rates of cancer screening of individuals with limited life expectancy suggest the importance of incorporating tools into clinical decision-making.
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Affiliation(s)
- Craig Evan Pollack
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland.,Department of Oncology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Amanda L Blackford
- Department of Oncology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Nancy L Schoenborn
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Cynthia M Boyd
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Kimberly S Peairs
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Eva H DuGoff
- Department of Population Health Sciences, University of Wisconsin, Madison, Wisconsin
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Sussman JB, Kerr EA, Saini SD, Holleman RG, Klamerus ML, Min LC, Vijan S, Hofer TP. Rates of Deintensification of Blood Pressure and Glycemic Medication Treatment Based on Levels of Control and Life Expectancy in Older Patients With Diabetes Mellitus. JAMA Intern Med 2015; 175:1942-9. [PMID: 26502220 PMCID: PMC9617259 DOI: 10.1001/jamainternmed.2015.5110] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Older patients with diabetes mellitus receiving medical treatment whose blood pressure (BP) or blood glucose level are potentially dangerously low are rarely deintensified. Given the established risks of low blood pressure and blood glucose, this is a major opportunity to decrease medication harm. OBJECTIVE To examine the rate of BP- and blood glucose-lowering medicine deintensification among older patients with type 1 or 2 diabetes mellitus who potentially receive overtreatment. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study conducted using data from the US Veterans Health Administration. Participants included 211 667 patients older than 70 years with diabetes mellitus who were receiving active treatment (defined as BP-lowering medications other than angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, or glucose-lowering medications other than metformin hydrochloride) from January 1 to December 31, 2012. Data analysis was performed December 10, 2013, to July 20, 2015. EXPOSURES Participants were eligible for deintensification of treatment if they had low BP or a low hemoglobin A1c (HbA1c) level in their last measurement in 2012. We defined very low BP as less than 120/65 mm Hg, moderately low as systolic BP of 120 to 129 mm Hg or diastolic BP (DBP) less than 65 mm Hg, very low HbA1c as less than 6.0%, and moderately low HbA1c as 6.0% to 6.4%. All other values were not considered low. MAIN OUTCOMES AND MEASURES Medication deintensification, defined as discontinuation or dosage decrease within 6 months after the index measurement. RESULTS The actively treated BP cohort included 211,667 participants, more than half of whom had moderately or very low BP levels. Of 104,486 patients with BP levels that were not low, treatment in 15.1% was deintensified. Of 25,955 patients with moderately low BP levels, treatment in 16.0% was deintensified. Among 81,226 patients with very low BP levels, 18.8% underwent BP medication deintensification. Of patients with very low BP levels whose treatment was not deintensified, only 0.2% had a follow-up BP measurement that was elevated (BP ≥140/90 mm Hg). The actively treated HbA1c cohort included 179,991 participants. Of 143,305 patients with HbA1c levels that were not low, treatment in 17.5% was deintensified. Of 23,769 patients with moderately low HbA1c levels, treatment in 20.9% was deintensified. Among 12,917 patients with very low HbA1c levels, 27.0% underwent medication deintensification. Of patients with very low HbA1c levels whose treatment was not deintensified, fewer than 0.8% had a follow-up HbA1c measurement that was elevated (≥7.5%). CONCLUSIONS AND RELEVANCE Among older patients whose treatment resulted in very low levels of HbA1c or BP, 27% or fewer underwent deintensification, representing a lost opportunity to reduce overtreatment. Low HbA1c or BP values or low life expectancy had little association with deintensification events. Practice guidelines and performance measures should place more focus on reducing overtreatment through deintensification.
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Affiliation(s)
- Jeremy B Sussman
- Department of Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan2Department of Internal Medicine, University of Michigan Medical School, Ann Arbor3Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Eve A Kerr
- Department of Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan2Department of Internal Medicine, University of Michigan Medical School, Ann Arbor3Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Sameer D Saini
- Department of Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan2Department of Internal Medicine, University of Michigan Medical School, Ann Arbor3Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Rob G Holleman
- Department of Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
| | - Mandi L Klamerus
- Department of Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
| | - Lillian C Min
- Department of Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan2Department of Internal Medicine, University of Michigan Medical School, Ann Arbor3Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Sandeep Vijan
- Department of Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan2Department of Internal Medicine, University of Michigan Medical School, Ann Arbor3Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Timothy P Hofer
- Department of Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan2Department of Internal Medicine, University of Michigan Medical School, Ann Arbor3Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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Abstract
Colorectal cancer is common worldwide, and the elderly are disproportionately affected. Increasing age is a risk factor for the development of precancerous adenomas and colorectal cancer, thus raising the issue of screening and surveillance in older patients. Elderly patients are a diverse and heterogeneous group, and special considerations such as comorbid medical conditions, functional status and cognitive ability play a role in deciding on the utility of screening and surveillance. Colorectal cancer screening can be beneficial to patients, but at certain ages and under some circumstances the harm of screening outweighs the benefits. Increasing adverse events, poorer bowel preparation and more incomplete examinations are observed in older patients undergoing colonoscopy for diagnostic, screening and surveillance purposes. Decisions regarding screening, surveillance and treatment for colorectal cancer require a multidisciplinary approach that accounts not only for the patient’s age but also for their overall health, preferences and functional status. This review provides an update and examines the challenges surrounding colorectal cancer diagnosis, screening, and treatment in the elderly.
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Affiliation(s)
- Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, San Francisco General Hospital and Trauma Center CA, USA
| | - Fernando Velayos
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, CA, USA
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Baker DW, Brown T, Goldman SN, Liss DT, Kollar S, Balsley K, Lee JY, Buchanan DR. Two-year follow-up of the effectiveness of a multifaceted intervention to improve adherence to annual colorectal cancer screening in community health centers. Cancer Causes Control 2015; 26:1685-90. [PMID: 26337733 DOI: 10.1007/s10552-015-0650-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 08/03/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE We previously found that a multifaceted outreach intervention achieved 82 % annual adherence to colorectal cancer (CRC) screening with fecal occult blood testing (FOBT). This study assessed adherence to FOBT after a second outreach. METHODS We followed 225 patients in community health centers in Chicago, Illinois, who were randomized to the intervention group. Our primary analysis focused on 124 patients who completed FOBT during the first outreach and were due again for annual FOBT; 90% were Latino, 87% preferred to speak Spanish, and 77% were uninsured. Second outreach consisted of (1) a mailed reminder letter, a free fecal immunochemical test (FIT) with postage-paid return envelope, (2) automated phone and text messages, (3) automated reminders 2 weeks later if the FIT was not returned, and (4) a telephone call after 3 months. Our main outcome was completion of FIT within 6 months of the due date. We also analyzed the proportion of the original 225 patients who were fully screened for CRC over the 2-year study period. RESULTS A total of 88.7% of patients completed a FIT within 6 months of their second outreach. Over the 2 years since the first outreach, 71.6% of the 225 patients assigned to the intervention group were fully up to date on CRC screening, another 11.1% had been screened suboptimally, and 17.3% were inadequately screened or not screened. CONCLUSIONS It is possible to achieve high rates of CRC screening over a 2-year period for vulnerable populations using outreach with FIT as a primary strategy.
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Affiliation(s)
- David W Baker
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA. .,Center for Advancing Equity in Clinical Preventive Services, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA. .,Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA. .,Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Tiffany Brown
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA. .,Center for Advancing Equity in Clinical Preventive Services, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Shira N Goldman
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA. .,Center for Advancing Equity in Clinical Preventive Services, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - David T Liss
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA. .,Center for Advancing Equity in Clinical Preventive Services, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | | | | | - Ji Young Lee
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA. .,Center for Advancing Equity in Clinical Preventive Services, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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27
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Cha JM. Would you recommend screening colonoscopy for the very elderly? Intest Res 2014; 12:275-80. [PMID: 25374492 PMCID: PMC4214953 DOI: 10.5217/ir.2014.12.4.275] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 02/11/2014] [Accepted: 02/11/2014] [Indexed: 12/31/2022] Open
Abstract
Life expectancy in Korea has increased, and the number of screening colonoscopies in the elderly has also dramatically increased. The net benefit of colonoscopy in the very elderly (≥80 years of age as defined by the World Health Organization) may be reduced because of the competing risk of mortality due to other diseases. Therefore, the decision to perform screening colonoscopy may be more complex in this age group. As the potential increase in life expectancy due to screening colonoscopy is significantly reduced in the very elderly, this procedure should be limited to those among the very elderly who have substantial life expectancies. Furthermore, considering the common major complications associated with colonoscopy, poor bowel preparation, and the possibility of incomplete colonoscopies in the very elderly, the performance of screening colonoscopy in the very elderly may not be an ideal recommendation. In terms of providing the greatest benefit to the most number of people, patients with the highest potential gain in terms of life expectancy, relative to the diagnostic yield, should be targeted for colonoscopy screening. This review addresses the unique considerations regarding screening colonoscopy in the very elderly and the individualized approach, which involves the weighing of the risks and benefits for each individual with consideration of their overall health status.
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Affiliation(s)
- Jae Myung Cha
- Department of Internal Medicine, Kyung Hee University Hospital at Gang Dong, Kyung Hee University School of Medicine, Seoul, Korea
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28
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Abstract
OPINION STATEMENT Colorectal cancer (CRC) disproportionately affects the elderly. Older age is a strong risk factor for both the development of precancerous adenomas and CRC, thus raising the issue of screening and surveillance in older patients. However, screening and surveillance decisions in the elderly can be complex and challenging. Elderly patients are a diverse and heterogeneous group and special considerations such as co-morbid medical conditions, functional status, and cognitive ability play a role in one's decisions regarding the utility of screening and surveillance. Such considerations also play a role in factors related to screening modalities, such as colonoscopy, as well as CRC treatment options and regimens. This review addresses many of the unique factors associated with CRC of the elderly and critically examines many of the controversies and challenges surrounding CRC in older patients.
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Affiliation(s)
- Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, San Francisco General Hospital and Trauma Center, 1001 Potrero Avenue, 3D-5, San Francisco, CA, 94110, USA,
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29
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Saini SD, Vijan S, Schoenfeld P, Powell AA, Moser S, Kerr EA. Role of quality measurement in inappropriate use of screening for colorectal cancer: retrospective cohort study. BMJ 2014; 348:g1247. [PMID: 24574474 PMCID: PMC3935739 DOI: 10.1136/bmj.g1247] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To examine whether the age based quality measure for screening for colorectal cancer is associated with overuse of screening in patients aged 70-75 in poor health and underuse in those aged over age 75 in good health. DESIGN Retrospective cohort study utilizing electronic data from the Veterans Affairs (VA) Health Care System, the largest integrated healthcare system in the United States. SETTING VA Health Care System. PARTICIPANTS Veterans aged ≥ 50 due for repeat average risk colorectal cancer screening at a primary care visit in fiscal year 2010. MAIN OUTCOME MEASURES Completion of colonoscopy, sigmoidoscopy, or fecal occult blood testing within 24 months of the 2010 visit. RESULTS 399,067 veterans met inclusion/exclusion criteria (mean age 67, 97% men). Of these, 38% had electronically documented screening within 24 months. In multivariable log binomial regression adjusted for Charlson comorbidity index, sex, and number of primary care visits, screening decreased markedly after the age of 75 (the age cut off used by the quality measure) (adjusted relative risk 0.35, 95% confidence interval 0.30 to 0.40). A veteran who was aged 75 and unhealthy (in whom life expectancy might be limited and screening more likely to result in net burden or harm) was significantly more likely to undergo screening than a veteran aged 76 and healthy (unadjusted relative risk 1.64, 1.36 to 1.97). CONCLUSIONS Specification of a quality measure can have important implications for clinical care. Future quality measures should focus on individual risk/benefit to ensure that patients who are likely to benefit from a service receive it (regardless of age), and that those who are likely to incur harm are spared unnecessary and costly care.
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Affiliation(s)
- Sameer D Saini
- Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, USA
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30
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Moore KL, Lewis CL, Zimmerman S, Ward K, Reed D, Rodriguez R, Kistler CE. A pilot study to examine colorectal cancer screening in two assisted living communities. J Am Geriatr Soc 2014; 62:386-8. [PMID: 24521371 DOI: 10.1111/jgs.12665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Kathryn L Moore
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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31
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Abstract
Colorectal cancer and precancerous adenomas disproportionately affect the elderly, necessitating the need for screening and surveillance in this group. However, screening and surveillance decisions in the elderly can be challenging. Special considerations such as comorbid medical conditions, functional status, and cognitive ability play a role in one's decisions regarding the utility of screening and surveillance as well as the success and safety of various screening modalities. This article explores the evidence for screening and surveillance in the elderly, and addresses key challenges unique to this population.
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Affiliation(s)
- Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, San Francisco General Hospital and Trauma Center, 1001 Potrero Avenue, 3D-5, San Francisco, CA 94110, USA.
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32
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von Wagner C, Macedo A, Campbell C, Simon AE, Wardle J, Hammersley V, Weller D, Waller J. Continuing cancer screening later in life: attitudes and intentions among older adults in England. Age Ageing 2013; 42:770-5. [PMID: 23999536 PMCID: PMC3942134 DOI: 10.1093/ageing/aft132] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: the rise in life expectancy, together with age-related increase in the incidence of most cancers, has led to mounting interest in cancer screening in older people. In England, routine invitations stop and an ‘opt-in’ (individual request) process is available from ages 71 to 76 years for breast and colorectal screening respectively. Little is known about public attitudes towards age-stoppage policy. Objective: this study examined public attitudes to current stoppage policy, information preferences and intentions to request screening beyond the age of routine invitations. Sample: participants (n = 927; age 60–74 years) were recruited as part of a TNS Research International survey and took part in home-based, computer-assisted interviews. Methods: measures included: (i) attitudes towards current stoppage policy, (ii) preference for communications about screening after the end of the routine invitation period and (iii) intention to opt-in. Results: the majority of respondents (78%) did not agree with age-based stoppage policies. Most (83%) wanted a strong recommendation to opt-in after this age, although the number who thought they would follow such a recommendation was much lower (27%). A majority of participants (54%) thought information on screening at older ages should come from their general practitioner (GP). Conclusion: this survey indicates that older people in England wish to continue to be actively invited for cancer screening, although only a minority think that they would ultimately take up the offer. Primary care may play a role in negotiating a shared decision that is based on individual circumstances.
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Affiliation(s)
- Christian von Wagner
- Department of Epidemiology and Public Health, Health Behaviour Research Centre, University College London, Gower Street, London WC1E 6BT, UK
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33
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Lewis CL, Esserman D, DeLeon C, Pignone MP, Pathman DE, Golin C. Physician decision making for colorectal cancer screening in the elderly. J Gen Intern Med 2013; 28:1202-7. [PMID: 23539281 PMCID: PMC3744317 DOI: 10.1007/s11606-013-2393-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Revised: 01/14/2013] [Accepted: 02/04/2013] [Indexed: 12/24/2022]
Abstract
BACKGROUND Although individualized decision making is recommended to appropriately screen for colorectal cancer (CRC) in older adults, it is unclear whether physicians solicit input from older patients before making a recommendation for or against CRC screening. OBJECTIVE The purpose of this study was to examine whether physicians elect to engage older patients in individualized decision making for CRC screening. DESIGN AND PARTICIPANTS We surveyed a random sample of 650 US primary care physicians by mail. Physicians responded to questions about three clinical vignettes involving 80-year-old female patients in good, fair, and poor health. We examined whether physicians reported that they would initiate a discussion with the patients about CRC screening and whether they would make a recommendation about screening or seek patient input first. RESULTS A total of 276 eligible physicians responded (52 % corrected response rate). Whether physicians indicated they would initiate a discussion about CRC screening varied by vignette: 91 % of physicians indicated they would do so for the patient in good health and 66 % and 44 % for the patients in fair and poor health, respectively (p<0.0001). The proportion of physicians that would seek patient input for their screening recommendation also varied by vignette (45 % for good, 49 % for fair, and 26 % for poor). CONCLUSION We found that physicians often individualize their CRC screening recommendations for older women by electing to engage patients in discussions and seeking their input before making a CRC recommendation. Physicians were more likely to elect to engage the patients represented by the good and fair health vignette, where the potential benefits likely outweigh the potential harms, than the patient in poor health, where the potential harms likely outweigh the potential benefits.
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Affiliation(s)
- Carmen L Lewis
- Department of Medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill, NC, USA.
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34
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Singal AG, Tiro JA, Gupta S. Improving hepatocellular carcinoma screening: applying lessons from colorectal cancer screening. Clin Gastroenterol Hepatol 2013; 11. [PMID: 23200983 PMCID: PMC3610769 DOI: 10.1016/j.cgh.2012.11.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatocellular carcinoma (HCC) screening is a complex process, with failure at any step in the process contributing to a gap between its efficacy and effectiveness. Important lessons can be learned from colorectal cancer (CRC) screening studies to improve the HCC screening process in clinical practice. Lack of provider recommendations is a barrier for both CRC and HCC screening; however, under-recognition of at-risk individuals appears to be unique to HCC. Future HCC screening interventions should help providers identify at-risk patients as well as promote ordering of HCC screening among those with cirrhosis. Patient adherence, a well-recognized barrier to CRC screening, does not appear to be a major issue in HCC screening. Poor patient adherence may become an important factor in the future when upstream provider-level factors are addressed. Other steps in the screening process, including radiology capacity and timely follow-up, have been demonstrated as barriers for CRC screening but have yet to be assessed for HCC screening. Overall, many lessons learned from challenges to CRC screening can be applied to rapidly optimize HCC screening delivery.
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Affiliation(s)
- Amit G Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas 75390-8887, USA.
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35
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Abstract
With increasing age, the incidence of both benign and malignant gastrointestinal (GI) disease rises. Endoscopic procedures are commonly performed in elderly and very elderly patients to diagnose and treat GI disorders. There are a number of issues to contemplate when considering performing an endoscopic procedure in an elderly patient, including the anticipated benefits of endoscopy as well as the increased risks associated with procedural sedation and some endoscopic procedures. This review will focus on the yield and safety of endoscopic procedures in older adults.
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36
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So C, Kirby KA, Mehta K, Hoffman RM, Powell AA, Freedland SJ, Sirovich B, Yano EM, Walter LC. Medical center characteristics associated with PSA screening in elderly veterans with limited life expectancy. J Gen Intern Med 2012; 27:653-60. [PMID: 22180196 PMCID: PMC3358397 DOI: 10.1007/s11606-011-1945-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Revised: 10/27/2011] [Accepted: 11/02/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND Although guidelines recommend against prostate-specific antigen (PSA) screening in elderly men with limited life expectancy, screening is common. OBJECTIVE We sought to identify medical center characteristics associated with screening in this population. DESIGN/PARTICIPANTS We conducted a prospective study of 622,262 screen-eligible men aged 70+ seen at 104 VA medical centers in 2003. MAIN MEASURES Primary outcome was the percentage of men at each center who received PSA screening in 2003, based on VA data and Medicare claims. Men were stratified into life expectancy groups ranging from favorable (age 70-79 with Charlson score = 0) to limited (age 85+ with Charlson score ≥1 or age 70+ with Charlson score ≥4). Medical center characteristics were obtained from the 1999-2000 VA Survey of Primary Care Practices and publicly available VA data sources. KEY RESULTS Among 123,223 (20%) men with limited life expectancy, 45% received PSA screening in 2003. Across 104 VAs, the PSA screening rate among men with limited life expectancy ranged from 25-79% (median 43%). Higher screening was associated with the following center characteristics: no academic affiliation (50% vs. 43%, adjusted RR = 1.14, 95% CI 1.04-1.25), a ratio of midlevel providers to physicians ≥3:4 (55% vs. 45%, adjusted RR = 1.20, 95% CI 1.09-1.32) and location in the South (49% vs. 39% in the West, adjusted RR = 1.25, 95% CI 1.12-1.40). Use of incentives and high scores on performance measures were not independently associated with screening. Within centers, the percentages of men screened with limited and favorable life expectancies were highly correlated (r = 0.90). CONCLUSIONS Substantial practice variation exists for PSA screening in older men with limited life expectancy across VAs. The high center-specific correlation of screening among men with limited and favorable life expectancies indicates that PSA screening is poorly targeted according to life expectancy.
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Affiliation(s)
- Cynthia So
- School of Medicine, University of California, San Francisco, CA USA
| | - Katharine A. Kirby
- Division of Geriatrics, San Francisco VA Medical Center and University of California, San Francisco, CA USA
| | - Kala Mehta
- Division of Geriatrics, San Francisco VA Medical Center and University of California, San Francisco, CA USA
| | - Richard M. Hoffman
- New Mexico VA Health Care System, Albuquerque and Department of Medicine, University of New Mexico, Albuquerque, NM USA
| | - Adam A. Powell
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System and Department of Medicine, University of Minnesota, Minneapolis, MN USA
| | - Stephen J. Freedland
- Durham VA Medical Center and Duke Prostate Center, Duke University, Durham, NC USA
| | | | - Elizabeth M. Yano
- VA HSR&D Center for the Study of Healthcare Provider Behavior, VA Greater Los Angeles Health System and Department of Health Services, UCLA School of Public Health, Los Angeles, CA USA
| | - Louise C. Walter
- Division of Geriatrics, San Francisco VA Medical Center and University of California, San Francisco, CA USA
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