Veterans' Attitudes Towards De-Intensification of Surveillance Colonoscopy for Low-Risk Adenomas

Multi-level Factors Influencing Decisions About Stopping Surveillance Colonoscopy in Older Adults: a Qualitative Study

BACKGROUND

Little is known about patient or provider experience and perceptions of stopping surveillance among older adults with a history of colon polyps. While guidelines recommend ceasing routine colorectal cancer screening in adults  > 75 years and those with limited life expectancy, guidance for ceasing surveillance colonoscopy in those with prior colon polyps suggests individualizing recommendations.

OBJECTIVE

Identify processes, experiences, and gaps around individualizing decisions to stop or continue surveillance colonoscopy for older adults and areas for improvement.

DESIGN

Phenomenological qualitative study design using recorded semi-structured interviews from May 2020 through March 2021.

PARTICIPANTS

15 patients aged  ≥ 65 in polyp surveillance, 12 primary care providers (PCPs), and 13 gastroenterologists (GIs).

APPROACH

Data were analyzed using a mixed deductive (directed content analysis) and inductive (grounded theory) approach to identify themes related to stopping or continuing surveillance colonoscopies.

KEY RESULTS

Analysis resulted in 24 themes and were clustered into three main categories: health and clinical considerations; communication and roles; and system-level processes or structures. Overall, the study found support for discussions around age 75-80 on stopping surveillance colonoscopy with considerations for health and life expectancy and that PCPs should take a primary role. However, systems and processes for scheduling surveillance colonoscopies largely bypass PCPs which reduces opportunities to both individualize recommendations and facilitate patients' decision-making.

CONCLUSIONS

This study identified gaps in processes to implement current guidelines for individualizing surveillance colonoscopy as adults grow older, including opportunities to discuss stopping. Increasing the role of PCPs in polyp surveillance as patients grow older provides more opportunities for individualized recommendations, so patients can consider their own preferences, ask questions, and make a more informed choice for themselves. Changing existing systems and processes and creating supportive tools for shared decision-making specific to older adults with polyps would improve how surveillance colonoscopy is individualized in this population.

Physician Decision-Making About Surveillance in Older Adults With Prior Adenomas: Results From a National Survey

INTRODUCTION

There is no clear guidance on when surveillance colonoscopies should stop in older adults with prior adenomas. We aimed to examine physicians' decision-making regarding surveillance colonoscopies in older adults.

METHODS

In a national mailed survey of 1,800 primary care physicians (PCP) and 600 gastroenterologists, we asked whether physicians would recommend surveillance colonoscopy in vignettes where we varied patient age (75 and 85 years), health (good, medium, and poor), and prior adenoma risk (low and high). We examined the association between surveillance recommendations and patient and physician characteristics using logistic regression. We also assessed decisional uncertainty, need for decision support, and decision-making roles.

RESULTS

Of 1,040 respondents (response rate 54.8%), 874 were eligible and included. Recommendation for surveillance colonoscopies was lower if patient was older (adjusted proportions 20.6% vs 49.8% if younger), in poor health (adjusted proportions 7.1% vs 28.8% moderate health, 67.7% good health), and prior adenoma was of low risk (adjusted proportions 29.7% vs 41.6% if high risk). Family medicine physicians were most likely and gastroenterologists were least likely to recommend surveillance (adjusted proportions 40.0% vs 30.9%). Approximately 52.3% of PCP and 35.4% of gastroenterologists reported uncertainty regarding the benefit/harm balance of surveillance in older adults. Most (85.9% PCP and 77.0% gastroenterologists) would find a decision support tool helpful. Approximately 32.8% of PCP vs 71.5% of gastroenterologists perceived it as the gastroenterologist's role to decide about surveillance colonoscopies.

DISCUSSION

Studies to better evaluate the benefits/harms of surveillance colonoscopy in older adults and decisional support tools that help physicians and patients incorporate such data are needed.

Impact of Knowledge and Risk Perceptions on Older Adults' Intention for Surveillance Colonoscopy

GOALS

The authors aimed to characterize older adults' intentions for future surveillance colonoscopy, knowledge of polyps, and predictors of colonoscopy plans.

BACKGROUND

Guidelines recommend that the decision to continue or stop surveillance colonoscopy in older adults with colon polyps be "individualized." Although older adults want to be included in decision making, how knowledge regarding polyps influences decisions is unknown.

STUDY

In collaboration with a rural family medicine practice, the authors invited adults aged 65 years and older with a history of colon adenomas to complete a 14-item survey regarding intention for colonoscopy and knowledge of colon polyps.

RESULTS

Sixty-seven of 105 (63%) patients completed the survey. The mean age was 72 years. Regarding future surveillance, 53% planned to return, 25% were unsure, and 22% did not plan to return. There were no significant differences in baseline characteristics on the basis of the intention for future colonoscopy. Regarding polyp knowledge, 73% had correct knowledge around how common polyps are; 50% thought that more than half of untreated polyps would become cancerous-an inaccurately elevated perception by 10 folds. Respondents who perceived polyps to have a high malignant potential were more likely to report plans for surveillance colonoscopy (68% vs. 39%; P=0.03).

CONCLUSIONS

In this survey of older adults with a history of polyps, many had a falsely elevated perception of polyps' potential for cancer that was associated with a higher intention for future colonoscopy. Ensuring older adults have an understanding of the risks of polyps is an essential step toward improving decision making around surveillance colonoscopy.

Older Adult Perspectives Toward Surveillance Colonoscopy: A Qualitative Study

GOALS AND BACKGROUND

Surveillance colonoscopy is the most common indication for colonoscopy in older adults, yet factors involved in patient decision-making are poorly defined. We sought to understand general perspectives of older adults toward surveillance colonoscopy.

STUDY

We conducted 2 in-person, 90-minute semistructured focus groups at a rural, tertiary care, academic facility with a total of 20 English-speaking participants with a history of colon polyps. We also obtained baseline characteristics including information to calculate life expectancy using the Schonberg Index, a validated measure of 5-year and 9-year mortality.

RESULTS

Participant ages ranged from 75 to 89, 67% were female, and 61% had a life expectancy of ≤9 years. Major common themes included reasons for and against getting a surveillance colonoscopy, and preferences and opinions surrounding discontinuing surveillance. Fear of cancer, trust in the colonoscopy procedure, and provider advice played prominent roles in patient decisions to return for surveillance. Most felt they should make screening decisions with input from providers, and that providers should engage them in these decisions and base recommendations on their patients' personal history and health, not on how old they are or on actuarial data.

CONCLUSIONS

This small, qualitative study suggests that older adults familiar with surveillance colonoscopy prefer patient-centered decision-making on when to discontinue testing and want support and information from providers when making choices. The evidence also suggests that participants value provider communication and trust their advice. Future work will use this information to create a larger patient survey on attitudes and beliefs toward surveillance colonoscopy.

Colorectal Cancer Screening and Surveillance Colonoscopy in Older Adults

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.