Colorectal cancer surveillance after age 65 years

Survival of elderly persons undergoing colonoscopy: implications for colorectal cancer screening and surveillance

BACKGROUND

In the elderly, the increased prevalence of colorectal neoplasia and the protective effect of colonoscopy may be offset by advancing age and comorbidity.

OBJECTIVE

To describe and quantify the endoscopic findings, survival, and predictors of mortality of elderly persons after colonoscopy.

DESIGN, SETTING, AND PATIENTS

Retrospective cohort study of persons aged>or=75 years who underwent colonoscopy in 1999 and 2000 at a U.S. Veterans Affairs facility and urban county hospital.

MAIN OUTCOME MEASURES

Advanced neoplasms were defined as colorectal cancer (CRC), polyp with high-grade dysplasia, villous histologic features, or tubular adenoma>or=1 cm. Comorbidity was measured with the Charlson comorbidity index. Subjects were followed until death or study closure.

RESULTS

Of 469 eligible subjects, 65 were excluded and 404 were included in the study. Fifty-nine of 404 (15%) had an advanced neoplasm, including 8 (2%) with CRC. There were 167 deaths (41%); the mean overall survival was 4.1+/-0.1 years (median 5.95 years). A symptomatic indication for colonoscopy was not predictive of death. Mortality was predicted by age (hazard ratio 1.16 for each year increase beyond age 75 years, 95% CI 1.07-1.3, P=.0003) and Charlson score (hazard ratio 8.3 for each point increase, 95% CI 1.4-48.5, P=.02). The median survival of patients aged 75 to 79 years was >5 years if the Charlson score was <or=4. Among patients aged>or=80 years, the median survival was <5 years regardless of Charlson score.

LIMITATIONS

Retrospective design.

CONCLUSIONS

In this cohort of elders, age and comorbidity were predictors of death. The protective effect of younger age lessens as comorbidity increases. These findings may have important implications for CRC screening and surveillance in elders.

Colonoscopic screening for colon cancer

Colonoscopic screening for colon cancer was suggested in 1988 [17], but it has only recently received significant acceptance. It is a topic of much current discussion among both health care providers and the general public, especially since the nationally broadcasted colonoscopy of a well-known television anchor person [8]. This brief discussion presents the role of colonoscopy in colon cancer screening. It sets forth the rationale for endoscopic screening, evaluates it using World Health Organization guidelines, and briefly considers the timing and termination of screening. By screening is meant the testing of asymptomatic individuals in a large population. This is to be distinguished from surveillance, which involves ongoing follow-up testing of individuals at known risk. The former is the subject of this discussion.

Colon and rectal cancer in the elderly

BACKGROUND

This is a retrospective study aimed to report short-term outcome among patients age > or =70 years surgically treated for colorectal cancer.

METHODS

All patients with the discharge diagnosis of colon and rectal cancer at St. Louis University Hospital from 1992 to 2002 were reviewed. Patients were assessed as to demographics, presenting symptoms, therapy, surgical morbidity and mortality.

RESULTS

One hundred eighty-one patients age > or =70 years with colorectal cancer were identified. The mean age was 78 years; 107/181 (59%) were females. Rectal bleeding and change in bowel habits were the most common presenting symptoms. Fifty-four out of 181 (30%) were asymptomatic at diagnosis. The diagnosis was made by colonoscopy in 75% of the patients. One hundred forty-three out of 181 (79%) had colon cancer; 38/181 (21%) had rectal cancer. Fourteen out of 181 (8%) did not undergo surgery. Twenty-two out of 181 (12%) were operated on as a surgical emergency. ASA classification was I-II in 52%, III in 34%, and IV-V in 14%. Nineteen out of 38 (50%) with rectal cancer underwent a sphincter-preserving procedure. Overall, there was a 29% major morbidity from surgery. Thirty-day mortality was 11% (21 deaths). Only the development of a postoperative complication predicted mortality.

CONCLUSIONS

Elderly patients tolerate surgery well for colon and rectal cancer in the short-term. Many patients are asymptomatic at diagnosis. Surgical emergencies are few and patients have a favorable stage of disease. This data supports aggressive detection of colorectal cancer in asymptomatic elderly patients who may harbor occult colorectal cancer.