Endoscopist Specialty Predicts the Likelihood of Recommending Cessation of Colorectal Cancer Screening in Older Adults

Association of Life Expectancy With Surveillance Colonoscopy Findings and Follow-up Recommendations in Older Adults

Importance

Surveillance after prior colon polyps is the most frequent indication for colonoscopy in older adults. However, to our knowledge, the current use of surveillance colonoscopy, clinical outcomes, and follow-up recommendations in association with life expectancy, factoring in both age and comorbidities, have not been studied.

Objective

To evaluate the association of estimated life expectancy with surveillance colonoscopy findings and follow-up recommendations among older adults.

Design, Setting, and Participants

This registry-based cohort study used data from the New Hampshire Colonoscopy Registry (NHCR) linked with Medicare claims data and included adults in the NHCR who were older than 65 years, underwent colonoscopy for surveillance after prior polyps between April 1, 2009, and December 31, 2018, and had full Medicare Parts A and B coverage and no Medicare managed care plan enrollment in the year prior to colonoscopy. Data were analyzed from December 2019 to March 2021.

Exposures

Life expectancy (<5 years, 5 to <10 years, or ≥10 years), estimated using a validated prediction model.

Main Outcomes and Measures

The main outcomes were clinical findings of colon polyps or colorectal cancer (CRC) and recommendations for future colonoscopy.

Results

Among 9831 adults included in the study, the mean (SD) age was 73.2 (5.0) years and 5285 (53.8%) were male. A total of 5649 patients (57.5%) had an estimated life expectancy of 10 or more years, 3443 (35.0%) of 5 to less than 10 years, and 739 (7.5%) of less than 5 years. Overall, 791 patients (8.0%) had advanced polyps (768 [7.8%]) or CRC (23 [0.2%]). Among the 5281 patients with available recommendations (53.7%), 4588 (86.9%) were recommended to return for future colonoscopy. Those with longer life expectancy or more advanced clinical findings were more likely to be told to return. For example, among patients with no polyps or only small hyperplastic polyps, 132 of 227 (58.1%) with life expectancy of less than 5 years were told to return for future surveillance colonoscopy vs 940 of 1257 (74.8%) with life expectancy of 5 to less than 10 years and 2163 of 2272 (95.2%) with life expectancy of 10 years or more (P < .001).

Conclusions and Relevance

In this cohort study, the likelihood of finding advanced polyps and CRC on surveillance colonoscopy was low regardless of life expectancy. Despite this observation, 58.1% of older adults with less than 5 years' life expectancy were recommended to return for future surveillance colonoscopy. These data may help refine decision-making about pursuing or stopping surveillance colonoscopy in older adults with a history of polyps.

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.

Colonoscopy utilization and outcomes in older adults: Data from the New Hampshire Colonoscopy Registry

BACKGROUND

Colonoscopy is frequently performed in older adults, yet data on current use, and clinical outcomes of and follow-up recommendations after colonoscopy in older adults are lacking.

METHODS

This was an observational study using the New Hampshire Colonoscopy Registry of adults age ≥65 years undergoing colonoscopy for screening, surveillance of prior polyps, or evaluation of symptoms. The main outcomes were clinical findings of polyps and colorectal cancer and recommendations for future colonoscopy by age.

RESULTS

Between 2009 and 2019, there were 42,611 colonoscopies, of which 17,527 (41%) were screening, 19,025 (45%) surveillance, and 6059 (14%) for the evaluation of symptoms. Mean age was 71.1 years (SD 5.0), and 49.3% were male. The finding of colorectal cancer was rare (0.71%), with the highest incidence among diagnostic examinations (2.4%). The incidence of advanced polyps increased with patient age from 65-69 to ≥85 years for screening (7.1% to 13.6%; p = 0.05) and surveillance (9.4% to 12.0%; p < 0.001). Recommendations for future colonoscopy decreased with age and varied by findings at current colonoscopy. In patients without any significant findings, 85% aged 70-74 years, 61.9% aged 75-79 years, 39.1% aged 80-84 years, and 27.4% aged ≥85 years (p < 0.001) were told to continue colonoscopy. Among patients with advanced polyps, 97.2% aged 70-74 years, 89.6% aged 75-79 years, 78.4% aged 80-84 years, and 66.7% aged ≥85 years were told to continue colonoscopy (p < 0.001).

CONCLUSIONS

Within this comprehensive statewide registry, clinical findings during colonoscopy varied by indication and increased with age. Overall rates of finding advanced polyps and colorectal cancer are low. Older adults are frequently recommended to continue colonoscopy despite advanced age and insignificant clinical findings on current examination. These data inform the potential benefits of ongoing colonoscopy, which must be weighed with the low but known potential immediate and long-term harms of colonoscopy, including cost, psychological distress, and long lag time to benefit exceeding life expectancy.

Recommendations for follow-up interval after colonoscopy with inadequate bowel preparation in a national colonoscopy quality registry

BACKGROUND AND AIMS

Endoscopist recommendations regarding a repeat colonoscopy after inadequate bowel cleanliness have not been fully described. Our aim was to evaluate the timing of recommendations for repeat colonoscopy after inadequate bowel preparation using a large, national colonoscopy registry.

METHODS

We performed a cross-sectional analysis of all outpatient screening and surveillance colonoscopies among adults ages 50 to 75 reported in the GI Quality Improvement Consortium from 2011 to 2018. The primary outcome was a recommendation to repeat colonoscopy within 1 year. Secondary outcomes were recommendations based on indication of colonoscopy and colonoscopy findings and predictors of a recommendation to follow-up within 1 year.

RESULTS

There were 260,314 colonoscopies with inadequate bowel preparation performed at 672 different sites by 4001 endoscopists. Of these, 31.9% contained a recommendation for follow-up within 1 year. This did not differ meaningfully by examination indication. The severity of colonoscopy findings influenced the recommendations for follow-up (within 1 year in 84.0% of cases with adenocarcinoma, 51.8% with any advanced lesion, and 23.2% with 1-2 small adenomas). Younger age, more severe pathology, location in the Northeast, and performance by an endoscopist with an adenoma detection rate ≥25% were associated with recommendations for follow-up within 1 year.

CONCLUSIONS

Only some colonoscopies with inadequate bowel preparation are recommended to be repeated within 1 year, which may have implications for potential missed lesions. Further understanding of reasons driving recommendations is an important next step to improving guideline-concordant colonoscopy practice.

Yield and Practice Patterns of Surveillance Colonoscopy Among Older Adults: An Analysis of the GI Quality Improvement Consortium

OBJECTIVES

There is little guidance regarding when to stop surveillance colonoscopy in individuals with a history of adenomas or colorectal cancer (CRC). We evaluated both yield and recommendations for follow-up colonoscopy in a large cohort of older individuals undergoing colonoscopy, using the GI Quality Improvement Consortium registry.

METHODS

We analyzed the yield of colonoscopy in adults aged ≥75 years, comparing those who had an indication of surveillance as opposed to an indication of diagnostic or screening, stratified by 5-year age groups. Our primary outcome was CRC and advanced lesions. We also evaluated recommended follow-up intervals by age and findings.

RESULTS

Between 2010 and 2017, 376,686 colonoscopies were performed by 3,976 endoscopists at 628 sites, of which 43.2% were for surveillance. Detection of CRC among surveillance patients increased with age from 0.51% (age 75-79 years) to 1.8% (age ≥ 90 years); however, these risks were lower when compared with both the diagnostic and screening for the same age band (P < 0.0001). Yield of advanced lesions also increased by every 5-year interval of age across all groups by indication. Even at the most advanced ages and in those with nonadvanced findings, only a minority of patients were recommended for no further colonoscopy. For example, in patients aged 90 years and older with only low risk findings, 62.9% were recommended to repeat colonoscopy.

DISCUSSION

Surveillance colonoscopy is frequently recommended at advanced ages even when recent findings may be clinically insignificant. Further work is needed to develop guidelines to inform best practice around when to stop surveillance in older adults.

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.