Impact of age and comorbidity on colorectal cancer screening among older veterans

Personalized Multilevel Intervention for Improving Appropriate Use of Colorectal Cancer Screening in Older Adults: A Cluster Randomized Clinical Trial

Importance

Despite guideline recommendations, clinicians do not systematically use prior screening or health history to guide colorectal cancer (CRC) screening decisions in older adults.

Objective

To evaluate the effect of a personalized multilevel intervention on screening orders in older adults due for average-risk CRC screening.

Design, Setting, and Participants

Interventional 2-group parallel unmasked cluster randomized clinical trial conducted from November 2015 to February 2019 at 2 US Department of Veterans Affairs (VA) facilities: 1 academic VA medical center and 1 of its connected outpatient clinics. Randomization at the primary care physician/clinician (PCP) level, stratified by study site and clinical full-time equivalency. Participants were 431 average-risk, screen-due US veterans aged 70 to 75 years attending a primary care visit. Data analysis was performed from August 2018 to August 2023.

Intervention

The intervention group received a multilevel intervention including a decision-aid booklet with detailed information on screening benefits and harms, personalized for each participant based on age, sex, prior screening, and comorbidity. The control group received a multilevel intervention including a screening informational booklet. All participants received PCP education and system-level modifications to support personalized screening.

Main Outcomes and Measures

The primary outcome was whether screening was ordered within 2 weeks of clinic visit. Secondary outcomes were concordance between screening orders and screening benefit and screening utilization within 6 months.

Results

A total of 436 patients were consented, and 431 were analyzed across 67 PCPs. Patients had a mean (SD) age of 71.5 (1.7) years; 424 were male (98.4%); 374 were White (86.8%); 89 were college graduates (21.5%); and 351 (81.4%) had undergone prior screening. A total of 258 (59.9%) were randomized to intervention, and 173 (40.1%) to control. Screening orders were placed for 162 of 258 intervention patients (62.8%) vs 114 of 173 control patients (65.9%) (adjusted difference, -4.0 percentage points [pp]; 95% CI, -15.4 to 7.4 pp). In a prespecified interaction analysis, the proportion receiving orders was lower in the intervention group than in the control group for those in the lowest benefit quartile (59.4% vs 71.1%). In contrast, the proportion receiving orders was higher in the intervention group than in the control group for those in the highest benefit quartile (67.6% vs 52.2%) (interaction P = .049). Fewer intervention patients (106 of 256 [41.4%]) utilized screening overall at 6 months than controls (96 of 173 [55.9%]) (adjusted difference, -13.4 pp; 95% CI, -25.3 to -1.6 pp).

Conclusions and Relevance

In this cluster randomized clinical trial, patients who were presented with personalized information about screening benefits and harms in the context of a multilevel intervention were more likely to receive screening orders concordant with benefit and were less likely to utilize screening.

Trial Registration

ClinicalTrials.gov Identifier: NCT02027545.

Frequency of Use and Outcomes of Colonoscopy in Individuals Older Than 75 Years

Importance

The benefits from colorectal cancer (CRC) screening may take 10 to 15 years to accrue. Therefore, screening is recommended for older adults who are in good health.

Objective

To determine the number of screening colonoscopies done in patients older than 75 years with a life expectancy of fewer than 10 years, diagnostic yield, and associated adverse events within 10 days and 30 days of the procedure.

Design

This cross-sectional study with a nested cohort between January 2009 and January 2022 in an integrated health system assessed asymptomatic patients older than 75 years who underwent screening colonoscopy in the outpatient setting. Reports with incomplete data, any indication other than screening, patients who had a colonoscopy within the previous 5 years, and patients with a personal history of inflammatory bowel disease or CRC were excluded.

Exposures

Life expectancy based on a prediction model from previous literature.

Main Outcomes and Measures

The primary outcome was the percentage of screened patients who had limited (<10 years) life expectancy. Other outcomes included colonoscopy findings and adverse events that developed within 10 days and 30 days of the procedure.

Results

A total of 7067 patients older than 75 years were included. The median (IQR) age was 78 (77-79) years, 3967 (56%) were women, and 5431 (77%) were White with an average of 2 comorbidities (taken from a select group of comorbidities). The proportion of colonoscopies performed on patients with a life expectancy of fewer than 10 years aged 76 to 80 years was 30% in both sexes and increased with age-82% of men and 61% of women aged 81 to 85 years (71% total), and 100% of patients beyond the age of 85 years. Adverse events requiring hospitalizations were common at 10 days (13.58 per 1000) and increased with age, particularly among patients older than 85 years. The detection of advanced neoplasia varied from 5.4% among patients aged 76 to 80 years to 6.2% in those aged 81 to 85 years and 9.5% among patients older than 85 years (P = .02). Of the total population, 15 patients (0.2%) had invasive adenocarcinoma; among patients with a life expectancy of fewer than 10 years, 1 of 9 was treated, whereas 4 of 6 patients with a life expectancy of greater than or equal to 10 years were treated.

Conclusions and Relevance

In this cross-sectional study with a nested cohort, most screening colonoscopies performed in patients older than 75 years were in patients with limited life expectancy and associated with increased risk of complications. Colorectal cancer was exceedingly rare.

Breast and prostate cancer screening rates by cognitive status in US older adults

INTRODUCTION

For most older adults with dementia, the short-term harms and burdens of routine cancer screening likely outweigh the delayed benefits. We aimed to provide a more updated assessment of the extent that US older adults with dementia receive breast and prostate cancer screenings.

METHODS

Using the Health and Retirement Study (HRS) Wave 12 (2014-2015) linked to Medicare, we examine rates of breast and prostate cancer screenings in adults 65+ years by cognitive status. We used claims data to identify eligibility for screening and receipt of screening. We used a validated method using HRS data to define cognitive status.

RESULTS

The analytic sample included 2439 women in the breast cancer screening cohort and 1846 men in the prostate cancer screening cohort. Average ages were 76.8 years for women and 75.6 years for men, with 9.0% and 7.6% with dementia in each cohort, respectively. Among women with dementia, 12.3% were screened for breast cancer. When stratified by age, 10.6% of those 75+ and have dementia were screened for breast cancer. When stratified by predicted life expectancy, 10.4% of those with predicted life expectancy of <10 years and have dementia were screened for breast cancer. Among men with dementia, 33.9% were screened for prostate cancer. When stratified by age, 30.9% of those 75+ and have dementia were screened for prostate cancer. When stratified by predicted life expectancy, 34.4% of those with predicted life expectancy of <10 years and have dementia were screened for prostate cancer. Using multivariable logistic regression, dementia was associated with lower odds of receiving breast cancer screening (OR 0.36, 95% CI 0.23-0.57) and prostate cancer screening (OR 0.58, 95% CI 0.36-0.96).

DISCUSSION

Our results suggest potential over-screening in older adults with dementia. Better supporting dementia patients and caregivers to make informed cancer screening decisions is critical.

Improved Survival in a Cohort of Patients Aged 75 Years and Older With Fecal Immunochemical Testing-Detected Colorectal Cancer

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 ).

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)

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.

Effect of a Patient Decision Aid on Preferences for Colorectal Cancer Screening Among Older Adults: A Secondary Analysis of a Randomized Clinical Trial

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.

Characteristics Associated with Low-Value Cancer Screening Among Office-Based Physician Visits by Older Adults in the USA

BACKGROUND

After a certain age, cancer screening may expose older adults to unnecessary harms with limited benefits and represent inefficient use of health care resources.

OBJECTIVE

To estimate the frequency of cervical, breast, and colorectal cancer screening among adults older than US Preventive Services Task Force (USPSTF) age thresholds at which screening is no longer considered routine and to identify physician and patient factors associated with low-value cancer screening.

DESIGN

Observational study using pooled cross-sectional data (2011-2016) from the National Ambulatory Medical Care Survey, a nationally representative probability sample of US office-based physician visits.

PARTICIPANTS

Analyses for cervical and breast cancer screening were limited to visits by women over age 65 (N=37,818) and ages 75 and over (N=19,451), respectively. Analyses for colorectal cancer screening were limited to visits by patients over age 75 (N=31,543).

MAIN MEASURES

Cancer screening procedures were coded as low value using USPSTF age thresholds.

KEY RESULTS

Between 2011 and 2016, an estimated 509, 507, and 273 thousand potentially low-value Pap smears, mammograms, and colonoscopies/sigmoidoscopies, respectively, were ordered annually. Low-valuecervical cancer screening was less likely to occur for visits with older (vs. younger) patients. Compared to visits by non-HispanicWhite women, low-valuecervical and breast cancer screening was less likely to occur for visits by women whose race/ethnicitywas something other than non-HispanicWhite, non-HispanicBlack, or Hispanic. Obstetrician/gynecologistswere more likely to order low-valuePap smears and mammograms compared to family/generalpractice physicians.

CONCLUSIONS

Thousands of cervical, breast, and colorectal cancer screenings at ages beyond routine guideline thresholds occur each year in the USA. Further research is needed to understand whether this pattern represents clinical inertia and resistance to de-adoption of previous screening practices, or whether physicians and/or patients perceive a higher value in these tests than that endorsed by experts writing evidence-based guidelines.

An Analysis of 5 Years of Randomized Trials in Gastroenterology and Hepatology Reveals 52 Medical Reversals

BACKGROUND AND AIMS

One manifestation of low-value medical practice is the medical reversal, a practice in widespread use that, once subjected to a randomized controlled trial (RCT), is found to be no better-or worse-than a prior established standard of care. We aimed to determine the prevalence of medical reversals in gastroenterology (GI) journals and characterize these reversals.

METHODS

We searched the American Journal of Gastroenterology, Clinical Gastroenterology and Hepatology, Gastroenterology, Gut, Hepatology, and the Journal of Hepatology, reviewing studies published in 2015-2019. We identified RCTs that tested an established clinical practice and produced negative results, considered tentative reversals. Any systematic review or meta-analysis that included the article was categorized as confirming the reversal, refuting the reversal, or providing insufficient data.

RESULTS

During the 5-year period, we identified 5,898 original articles, of which 212 tested an established practice and 52 were categorized as unrefuted medical reversals (25% of articles testing standard of care). Of the reversals, 21 (40%) tested procedures and devices, 15 (29%) tested medications, and 8 (15%) tested vitamins/supplements/diet. Twenty-three (44%) considered the alimentary tract, 12 (23%) considered the liver, pancreas, or biliary tract, and 17 (33%) considered endoscopy. Thirty-eight (73%) were funded exclusively by non-industry sources.

CONCLUSION

This review reveals a total of 52 reversals across all subfields of GI and medical, procedural, screening, and diagnostic interventions, occurring in 25% of randomized trials testing an established practice. More research is needed to determine the optimal way to engage stakeholders and remove reversed practices from medical care.

Predicting Life Expectancy to Target Cancer Screening Using Electronic Health Record Clinical Data

BACKGROUND

Guidelines recommend breast and colorectal cancer screening for older adults with a life expectancy >10 years. Most mortality indexes require clinician data entry, presenting a barrier for routine use in care. Electronic health records (EHR) are a rich clinical data source that could be used to create individualized life expectancy predictions to identify patients for cancer screening without data entry.

OBJECTIVE

To develop and internally validate a life expectancy calculator from structured EHR data.

DESIGN

Retrospective cohort study using national Veteran's Affairs (VA) EHR databases.

PATIENTS

Veterans aged 50+ with a primary care visit during 2005.

MAIN MEASURES

We assessed demographics, diseases, medications, laboratory results, healthcare utilization, and vital signs 1 year prior to the index visit. Mortality follow-up was complete through 2017. Using the development cohort (80% sample), we used LASSO Cox regression to select ~100 predictors from 913 EHR data elements. In the validation cohort (remaining 20% sample), we calculated the integrated area under the curve (iAUC) and evaluated calibration.

KEY RESULTS

In 3,705,122 patients, the mean age was 68 years and the majority were male (97%) and white (85%); nearly half (49%) died. The life expectancy calculator included 93 predictors; age and gender most strongly contributed to discrimination; diseases also contributed significantly while vital signs were negligible. The iAUC was 0.816 (95% confidence interval, 0.815, 0.817) with good calibration.

CONCLUSIONS

We developed a life expectancy calculator using VA EHR data with excellent discrimination and calibration. Automated life expectancy prediction using EHR data may improve guideline-concordant breast and colorectal cancer screening by identifying patients with a life expectancy >10 years.

Current and future colorectal cancer screening strategies

Despite strong evidence of effectiveness, colorectal cancer (CRC) screening remains underused. Currently, there are several options for CRC screening, each with its own performance characteristics and considerations for practice. This Review aims to cover current CRC screening guidelines and highlight future blood-based and imaging-based options for screening. In current practice, the leading non-invasive option is the faecal immunochemical test (FIT) based on its high specificity, good sensitivity, low cost and ease of use in mailed outreach programmes. There are currently five blood-based CRC screening tests in varying stages of evaluation, including one that is currently sold in the USA as a laboratory-developed test. There are ongoing studies on the diagnostic accuracy and longitudinal performance of blood tests and they have the potential to disrupt the CRC screening landscape. Imaging-based options, including the colon capsule, MR colonography and the CT capsule, are also being tested in active studies. As the world attempts to recover from the COVID-19 pandemic and adapts to the start of CRC screening among people at average risk starting at age 45 years, non-invasive options will become increasingly important.

Patient-Reported Factors Associated With Older Adults' Cancer Screening Decision-making: A Systematic Review

IMPORTANCE

Decisions for older adults (aged ≥65 years) and their clinicians about whether to continue to screen for cancer are not easy. Many older adults who are frail or have limited life expectancy or comorbidities continue to be screened for cancer despite guidelines suggesting they should not; furthermore, many older adults have limited knowledge of the potential harms of continuing to be screened.

OBJECTIVE

To summarize the patient-reported factors associated with older adults' decisions regarding screening for breast, prostate, colorectal, and cervical cancer.

EVIDENCE REVIEW

Studies were identified by searching databases from January 2000 to June 2020 and were independently assessed for inclusion by 2 authors. Data extraction and risk of bias assessment were independently conducted by 2 authors, and then all decisions were cross-checked and discussed where necessary. Data analysis was performed from September to December 2020.

FINDINGS

The search yielded 2475 records, of which 21 unique studies were included. Nine studies were quantitative, 8 were qualitative, and 4 used mixed method designs. Of the 21 studies, 17 were conducted in the US, and 10 of 21 assessed breast cancer screening decisions only. Factors associated with decision-making were synthesized into 5 categories: demographic, health and clinical, psychological, physician, and social and system. Commonly identified factors associated with the decision to undergo screening included personal or family history of cancer, positive screening attitudes, routine or habit, to gain knowledge, friends, and a physician's recommendation. Factors associated with the decision to forgo screening included being older, negative screening attitudes, and desire not to know about cancer. Some factors had varying associations, including insurance coverage, living in a nursing home, prior screening experience, health problems, limited life expectancy, perceived cancer risk, risks of screening, family, and a physician's recommendation to stop.

CONCLUSIONS AND RELEVANCE

Although guidelines suggest incorporating life expectancy and health status to inform older adults' cancer screening decisions, older adults' ingrained beliefs about screening may run counter to these concepts. Communication strategies are needed that support older adults to make informed cancer screening decisions by addressing underlying screening beliefs in context with their perceived and actual risk of developing cancer.

Navigating the Cancer Screening Decision for Patients with Dementia

PURPOSE OF REVIEW

The risks of developing cancer and dementia both increase with age, giving rise to the complex question of whether continued cancer screening for older dementia patients is appropriate. This paper offers a practice-based clinical approach to determine an answer to this challenging question.

RECENT FINDINGS

There is no consensus on the prevalence of cancer and dementia as co-diagnoses. Persons with dementia are screened less often compared to those without dementia. There is significant literature focusing on screening in the geriatric population, but there is little evidence to support decision-making for screening for older patients with dementia. Given this lack of evidence, individualized decisions should be made in collaboration with patients and family caregivers. Four considerations to help guide this process include prognosis, behavioral constraints, cognitive capacity, and goals for care. Future research will be challenging due to variability of factors that inform screening decisions and the vulnerable nature of this patient population.

Comorbidity Profiles and Lung Cancer Screening among Older Adults: U.S. Behavioral Risk Factor Surveillance System 2017 to 2019

RATIONALE

Although lung cancer screening (LCS) with low-dose computed tomography (LDCT) is now recommended for those meeting standard risk factor-based eligibility criteria, the role of comorbidity in the uptake of LCS with LDCT in an older real-world U.S. population is not well established.

OBJECTIVE

To examine the relationships between comorbidity, functional status and LCS utilization in the United States.

METHODS

Using population-based data from the 2017-2019 Behavioral Risk Factor Surveillance System (BRFSS), we examined the association of comorbid conditions and functional limitations regarding activities of daily living with LCS utilization among participants that met the LCS criteria based on the US Preventive Service Taskforce guidelines. We employed multivariable weighted logistic regression models to evaluate these associations, both overall and within subgroups defined by age (<65 vs. ≥65 years), gender, and smoking history.

RESULTS

Of 11,214 participants that met the eligibility criteria for LCS, 1731 (16%) underwent LCS with LDCT. The majority were white (90%), male (55%), former smokers (52%) and living with at least one chronic comorbid condition (77%). Over 28% had 3 or more comorbid conditions and approximately 40% of participants reported having some form of functional limitations. In the multivariable models, the likelihood of undergoing LCS with LDCT within the past year was positively associated with higher levels of comorbidity (≥5 vs. 0: aOR=2.34, 95% CI=1.22,4.48) but not with functional limitations (≥3 vs. 0: aOR=1.00, 95% CI=0.66, 1.50).

CONCLUSION

The presence of comorbid conditions is associated with a higher likelihood of undergoing LCS with LDCT. Because poor health status may diminish the benefits of screening, future research is needed to precisely characterize the health status of LCS-eligible individuals.

A stepped randomized trial to promote colorectal cancer screening in a nationwide sample of U.S. Veterans

BACKGROUND

Colorectal cancer (CRC) screening (CRCS) facilitates early detection and lowers CRC mortality.

OBJECTIVES

To increase CRCS in a randomized trial of stepped interventions. Step 1 compared three modes of delivery of theory-informed minimal cue interventions. Step 2 was designed to more intensively engage those not completing CRCS after Step 1.

METHODS

Recruitment packets (60,332) were mailed to a random sample of individuals with a record of U.S. military service during the Vietnam-era. Respondents not up-to-date with CRCS were randomized to one of four Step 1 groups: automated telephone, telephone, letter, or survey-only control. Those not completing screening after Step 1 were randomized to one of three Step 2 groups: automated motivational interviewing (MI) call, counselor-delivered MI call, or Step 2 control. Intention-to-treat (ITT) analyses assessed CRCS on follow-up surveys mailed after each step.

RESULTS

After Step 1 (n = 1784), CRCS was higher in the letter, telephone, and automated telephone groups (by 1%, 5%, 7%) than in survey-only controls (43%), although differences were not statistically significant. After Step 2 (n = 516), there were nonsignificant increases in CRCS in the two intervention groups compared with the controls. CRCS following any combination of stepped interventions overall was 7% higher (P = 0.024) than in survey-only controls (55.6%).

CONCLUSIONS

In a nationwide study of Veterans, CRCS after each of two stepped interventions of varying modes of delivery did not differ significantly from that in controls. However, combined overall, the sequence of stepped interventions significantly increased CRCS.

Factors Influencing Utilization of Preventive Health Services in Primary Health Care in the Republic of Serbia

The use of preventive health services is a long-term health investment due to its potential to help individuals to take care of their health. This study aimed to explore the availability and performance of health services in primary health care (PHC) in the domain of general practice (GP), pediatrics, and gynecology, as well as to analyze the influence of sociodemographic and health determinants on the utilization of preventive health services. This descriptive study used data from the National Health Insurance Fund and the Statistical Office of the Republic of Serbia for 2015 and included 149 independent PHC units. The relationship between the utilization of preventive services and sociodemographic and health characteristics of the population was analyzed by bivariate and multivariate linear regression models. The higher health expenditure per capita and noncommunicable diseases mortality rate were, the more preventive health services were provided by a chosen GP. Children with a higher completion rate of primary school (p = 0.024), higher health expenditure (p = 0.017), and higher life expectancy at birth (p = 0.041) had more preventive health services. The fertility rate was positively associated with the number of preventive health services per 1000 women (p = 0.033). Our findings should serve as a starting point for where efforts should be made to achieve better health outcomes.

ACG Clinical Guidelines: Colorectal Cancer Screening 2021

Colorectal cancer (CRC) is the third most common cancer in men and women in the United States. CRC screening efforts are directed toward removal of adenomas and sessile serrated lesions and detection of early-stage CRC. The purpose of this article is to update the 2009 American College of Gastroenterology CRC screening guidelines. The guideline is framed around several key questions. We conducted a comprehensive literature search to include studies through October 2020. The inclusion criteria were studies of any design with men and women age 40 years and older. Detailed recommendations for CRC screening in average-risk individuals and those with a family history of CRC are discussed. We also provide recommendations on the role of aspirin for chemoprevention, quality indicators for colonoscopy, approaches to organized CRC screening and improving adherence to CRC screening. CRC screening must be optimized to allow effective and sustained reduction of CRC incidence and mortality. This can be accomplished by achieving high rates of adherence, quality monitoring and improvement, following evidence-based guidelines, and removing barriers through the spectrum of care from noninvasive screening tests to screening and diagnostic colonoscopy. The development of cost-effective, highly accurate, noninvasive modalities associated with improved overall adherence to the screening process is also a desirable goal.

Cognitive impairment in older adults with cancer

PURPOSE OF REVIEW

Cognitive impairment is increasing in an ageing population and as people live longer, they are more likely to develop cancer therefore cognitive impairment and cancer are frequently co-occurring. We reviewed articles published since 2018 on cognitive impairment and cancer.

RECENT FINDINGS

The current review has focused on diagnosis, treatment and palliative and end of life care. A comprehensive systematic review reported joint cancer and cognitive impairment prevalence from 0.2 to 45.6%. The review reported there was reduced likelihood of patients with co-occurring cognitive and cancer receiving information regarding cancer stage, reduced cancer treatment with curative intent and limited pain and symptom management. Further studies emphasized the role of family carers in supporting patients with cognitive impairment through cancer treatment.

SUMMARY

Disappointingly in an area where the numbers of patients with cognitive impairment and cancer are increasing, there appears to be little recently published research in this area. We conclude that further research is required to determine how best to support patients with cognitive impairment and cancer and families during diagnosis of cancer, treatment and continuing care and most importantly the findings of all studies are implemented within clinical practice.

Associations of multimorbidity with breast, cervical, and colorectal cancer screening delivery: a cross-sectional study of a nationally representative Japanese sample

BACKGROUND

Multimorbidity is associated with a high mortality rate and low health-related quality of life. Previous studies have indicated that multimorbidity tends to be associated with not receiving cancer screening, although this association remains unclear. This study aimed to investigate the associations between multimorbidity and the delivery of breast, cervical, and colorectal cancer screening in Japan, and to identify subgroups that did not receive cancer screening.

METHODS

This study used cross-sectional data from the 2016 Comprehensive Survey of Living Conditions, which used a stratified random sample of the general Japanese population. Multivariable logistic regression models were used to evaluate the associations between the number of chronic conditions and each cancer's screening proportion. The relevant covariates included age, marital status, education level, occupation, and household income.

RESULTS

Relative to subjects with no chronic conditions, subjects with two chronic conditions received more screening for breast, cervical, and colorectal cancers (breast cancer, adjusted odds ratio [aOR]: 5.42, 95% confidence interval [CI]: 2.80-10.5; cervical cancer, aOR: 4.59, 95% CI: 2.03-10.4; male colorectal cancer, aOR: 3.26, 95% CI: 1.29-8.24; female colorectal cancer, aOR: 1.05, 95% CI: 0.39-2.81). Low socioeconomic status was associated with not receiving any type of cancer screening consistently.

CONCLUSION

Multimorbidity and high socioeconomic status were associated with higher proportions of screening for breast, cervical, and colorectal cancers in the Japanese population. More aggressive strategies may be needed to promote screening among Japanese individuals with no chronic conditions and individuals with low socioeconomic status.

Colorectal cancer screening among Hispanics in the United States: Disparities, modalities, predictors, and regional variation

Hispanics represent the largest and one of the fastest growing minority populations in the U.S. and have lower survival from colorectal cancer (CRC) than non-Hispanic Whites (NHW). We aimed to examine screening modalities, predictors, and regional disparities among Hispanics and NHW in the U.S. by conducting a cross-sectional analysis of Hispanic participants age 50 to 75 from the 2016 Behavioral Risk Factor Surveillance System (BRFSS) survey. The primary outcome was self-reported CRC screening status. We used the Rao-Scott Chi-square test to compare screening rates and modalities in NHWs and Hispanics. We also used univariable and multivariable logistic regression to determine predictors of screening among Hispanics and calculated Hispanic-NHW screening rate differences for each U.S. state/territory as a measure of regional screening disparities. The screening rate was 53.4% for Hispanics (N = 12,395), compared to 70.4% for NHWs (N = 186,331) (p < 0.001). Among Hispanics, colonoscopy was most common (75.9%). Uninsured status (aOR = 0.51; 95% CI = 0.38-0.70) and limited access to medical care (aOR = 0.38; 95% CI = 0.29-0.49) predicted lack of screening. States/territories with the largest screening disparities were North Carolina (33.9%), Texas (28.3%), California (25.1%), and Nebraska (25.6%). Disparities were smallest in New York (2.6%), Indiana (3.1%), and Delaware (4.0%). In Ohio and Guam, Hispanics had higher screening rates than NHWs. In conclusion, Hispanics have lower CRC screening rates than NHWs across most U.S. states/territories; however, the disparity varies by region. Future efforts must address multi-level barriers to screening among Hispanics and target regions with low rates to improve CRC outcomes in this growing population.

What Is Organized Screening and What Is Its Value?

Most screening in the United States occurs in an opportunistic fashion, although organized screening occurs in some integrated health care systems. Organized colorectal cancer (CRC) screening consists of an explicit screening policy, defined target population, implementation team, health care team for clinical care delivery, quality assurance infrastructure, and method for identifying cancer outcomes. Implementation of an organized screening program offers opportunities to systematically assess the success of the program and develop interventions to address identified gaps in an effort to optimize CRC outcomes. There is evidence of that organized screening is associated with improvements in screening participation and CRC mortality.

The Impact of Colorectal Cancer Screening in a Veteran Hospital Population

Colon and rectal cancer is the second most common cause of cancer death in the United States. Screening effectively decreases colorectal cancer mortality. This study aims to evaluate the impact of colorectal cancer screening within a Veterans Affairs Medical Center and treatment outcomes. Institutional Review Board approval was obtained for a retrospective analysis of all colorectal cancer cases that were identified through the Tumor Registry of the Robley Rex VA Medical Center from 2000 to 2009. Data collected included age at diagnosis, race, risk factors, diagnosis by screening versus symptomatic evaluation, screening test, tumor location and stage, operation performed, operative mortality, and survival. A value of P < 0.05 on Fisher's exact, χ2, analysis of variance, or Cox regression analyses was considered significant. Three hundred fifty-four patients with colorectal cancer (255 colon, 99 rectal) were identified. One hundred twenty-one patients (34%) were diagnosed by screening. In comparison with those diagnosed by symptom evaluation (n = 233), these patients had earlier stage cancers, were more likely to have a curative intent procedure, and had improved 5-year survival rates. Older patients (older than 75 years old) were more likely to present with symptoms. High-risk patients were more likely to have colonoscopic screening than fecal occult blood testing. More blacks had Stage IV disease than nonblacks. Curative intent 30-day operative mortality was 2.1 per cent for colectomy and 0 per cent for rectal resection. Screening for colorectal cancer in the veteran population allows for better survival, detection at an earlier stage, and higher likelihood of resection.

The association of chronic diseases and mammography among Medicare beneficiaries living in Appalachia

OBJECTIVE

This study assessed the relationship between presence and number of chronic disease and reception of mammogram in women 65 years and older, and how this relationship is influenced by primary care provider visits.

METHODS

A total of 3306 women diagnosed with breast cancer from 2006 to 2008 from cancer registries in four Appalachian states were analyzed.

RESULTS

Having a mammogram within the past 2 years was associated with having at least one chronic disease. The presence of a chronic disease was associated with an increased likelihood of breast cancer screening adherence but was not a strong predictor when demographic variables were added.

CONCLUSION

This study supports the findings that women with more primary care provider visits were more likely to adhere to breast cancer screening guidelines but having several chronic diseases presents a barrier to achieving guideline-concordant mammography screening, highlighting the importance of preventive screening for patients managing chronic diseases.

Comorbid chronic diseases and cancer diagnosis: disease-specific effects and underlying mechanisms

An earlier diagnosis is a key strategy for improving the outcomes of patients with cancer. However, achieving this goal can be challenging, particularly for the growing number of people with one or more chronic conditions (comorbidity/multimorbidity) at the time of diagnosis. Pre-existing chronic diseases might affect patient participation in cancer screening, help-seeking for new and/or changing symptoms and clinicians' decision-making on the use of diagnostic investigations. Evidence suggests, for example, that pre-existing pulmonary, cardiovascular, neurological and psychiatric conditions are all associated with a more advanced stage of cancer at diagnosis. By contrast, hypertension and certain gastrointestinal and musculoskeletal conditions might be associated with a more timely diagnosis. In this Review, we propose a comprehensive framework that encompasses the effects of disease-specific, patient-related and health-care-related factors on the diagnosis of cancer in individuals with pre-existing chronic illnesses. Several previously postulated aetiological mechanisms (including alternative explanations, competing demands and surveillance effects) are integrated with newly identified mechanisms, such as false reassurances, or patient concerns about appearing to be a hypochondriac. By considering specific effects of chronic diseases on diagnostic processes and outcomes, tailored early diagnosis initiatives can be developed to improve the outcomes of the large proportion of patients with cancer who have pre-existing chronic conditions.

Race, Poverty, and Mental Health Drive Colorectal Cancer Screening Disparities in the Veterans Health Administration

INTRODUCTION

Colorectal cancer (CRC) is a common but largely preventable malignancy. Screening is recommended for all adults aged 50-75 years; however, screening rates are low nationally and vary by patient factors and across health care systems. It is currently unknown whether there are inequities in CRC screening rates by patient sociodemographic and/or clinical factors in the Veterans Health Administration (VA) where the majority of patients are CRC screening-eligible age and CRC is the third most commonly diagnosed cancer.

METHODS

We performed a retrospective cohort study using VA national clinical performance and quality data to determine the overall CRC screening rate, rates by patient sociodemographic and clinical factors, and predictors of screening adjusting for patient and system factors. We also determined whether disparities in screening exist in VA.

RESULTS

The overall CRC screening rate in VA was 81.5%. Screening rates were lowest among American Indians/Alaska Natives [75.3%; adjusted odds ratio (aOR)=0.77, 95% confidence interval (CI)=0.65-0.90], those with serious mental illness (75.8%; aOR=0.65, 95% CI=0.61-0.69), those with substance abuse (76.9%; aOR=0.76, 95% CI=0.72-0.80), and those in the lowest socioeconomic status quintile (79.5%; aOR=1.10-1.31 for quintiles 2-5 vs. lowest quintile 1). Increasing age, Hispanic ethnicity, black race, Asian race, and high comorbidity were significant predictors of screening uptake.

CONCLUSIONS

Many racial/ethnic disparities in CRC screening documented in non-VA settings do not exist in VA. Nonetheless, overall high VA CRC screening rates have not reached American Indians/Alaska Natives, low socioeconomic status groups, and those with mental illness and substance abuse. These groups might benefit from additional targeted efforts to increase screening uptake.

Unrelated Death After Colorectal Cancer Screening: Implications for Improving Colonoscopy Referrals

The observed mortality < 5 years after the index colonoscopy lowered the overall impact of screening, which should prompt health care providers to perform a more thorough assessment of the potential reduced benefit for individual veterans when incorporating cancer risk, comorbidity burden, and age-based criteria.

Medicare Cancer Screening in the Context of Clinical Guidelines: 2000 to 2012

OBJECTIVES

Cancer screening is a ubiquitous and controversial public health issue, particularly in the elderly population. Despite extensive evidence-based guidelines for screening, it is unclear how cancer screening has changed in the Medicare population over time. We characterize trends in cancer screening for the most common cancer types in the Medicare fee-for-service (FFS) program in the context of conflicting guidelines from 2000 to 2012.

MATERIALS AND METHODS

We performed a descriptive analysis of retrospective claims data from the Medicare FFS program based on billing codes. Our data include all claims for Medicare part B beneficiaries who received breast, colorectal (CRC), or prostate cancer screening from 2000 to 2012 based on billing codes. We utilize a Monte Carlo permutation method to detect changes in screening trends.

RESULTS

In total, 231,416,732 screening tests were analyzed from 2000 to 2012, representing an average of 436.8 tests per 1000 beneficiaries per year. Mammography rates declined 7.4%, with digital mammography extensively replacing film. CRC cancer screening rates declined overall. As a percentage of all CRC screening tests, colonoscopy grew from 32% to 71%. Prostate screening rates increased 16% from 2000 to 2007, and then declined to 7% less than its 2000 rate by 2012.

DISCUSSION

Both the aggressiveness of screening guidelines and screening rates for the Medicare FFS population peaked and then declined from 2000 to 2012. However, guideline publications did not consistently precede utilization trend shifts. Technology adoption, practical and financial concerns, and patient preferences may have also contributed to the observed trends. Further research should be performed on the impact of multiple, conflicting guidelines in cancer screening.

Development and validation of a 5-year mortality prediction model using regularized regression and Medicare data

PURPOSE

De-implementation of low-value services among patients with limited life expectancy is challenging. Robust mortality prediction models using routinely collected health care data can enhance health care stakeholders' ability to identify populations with limited life expectancy. We developed and validated a claims-based prediction model for 5-year mortality using regularized regression methods.

METHODS

Medicare beneficiaries age 66 or older with an office visit and at least 12 months of pre-visit continuous Medicare A/B enrollment were identified in 2008. Five-year mortality was assessed through 2013. Secondary outcomes included 30-, 90-, and 180-day and 1-year mortality. Claims-based predictors, including comorbidities and indicators of disability, frailty, and functional impairment, were selected using regularized logistic regression, applying the least absolute shrinkage and selection operator (LASSO) in a random 80% training sample. Model performance was assessed and compared with the Gagne comorbidity score in the 20% validation sample.

RESULTS

Overall, 183 204 (24%) individuals died. In addition to demographics, 161 indicators of comorbidity and function were included in the final model. In the validation sample, the c-statistic was 0.825 (0.823-0.828). Median-predicted probability of 5-year mortality was 14%; almost 4% of the cohort had a predicted probability greater than 80%. Compared with the Gagne score, the LASSO model led to improved 5-year mortality classification (net reclassification index = 9.9%; integrated discrimination index = 5.2%).

CONCLUSIONS

Our claims-based model predicting 5-year mortality showed excellent discrimination and calibration, similar to the Gagne score model, but resulted in improved mortality classification. Regularized regression is a feasible approach for developing prediction tools that could enhance health care research and evaluation of care quality.

Rural–urban disparities in colorectal cancer screening among military service members and Veterans

Introduction: Little is known about rural–urban disparities in colorectal cancer (CRC) screening rates among the military service member and Veteran (SMV) population in the United States. Given that health care access is a challenge in rural areas, we sought to determine whether rural-dwelling Veterans were less likely to be screened for CRC than urban-dwelling Veterans. Methods: Secondary data for this cross-sectional study were retrieved from the 2016 Behavioral Risk Factor Surveillance System for a national sample of non-institutionalized SMVs ( N = 63,919). The influence of rurality on CRC screening among SMVs was determined using maximum likelihood multiple logistic regression. Results: After controlling for relevant covariates, rurality was independently associated with decreased likelihood of meeting guidelines for CRC screening among SMVs (odds ratio = 0.83, 95% confidence interval, 0.76–0.90). Discussion: Innovative interventions for CRC screening should target SMVs in rural areas because doing so may lower mortality from CRC.

Utilization of Colorectal Cancer Screening among Saudi Elderly Population: A Study from the Saudi National Survey for Elderly Health

Objective: The goal of this study was to measure colorectal cancer screening (CRCS) utilization in Saudi Arabia ’s elderly population and to assess the factors associated with CRCS. Methods: The Saudi National Survey for Elderly Health was used to examine CRCS utilization. It is a nationally representative population-based cross-sectional survey that was conducted between 2006-2007. Utilization of CRCS was defined as any colonoscopy during the last five years or fecal occult blood test (FOBT) during the twelve months before the interview. Multivariable logistic regression was used to assess patients’ demographics, co-morbidities, number of visits to primary health clinics, and hospital availability and accessibility impact on CRCS. Results: The prevalence of CRCS utilization among Saudi elderly population was 5.64%. The fecal occult blood test was done in 4.4% of subjects while scope use was performed in 0.55%. In addition, 0.69% of patients have gone through both FOBT and scope use. Having blood in stools (OR=2.80; 95%CI: 1.3-6.00), Self-drivers (OR= 2.52) private driver (OR=2.1; 95%CI: 1.15-3.7) having 4 or more visits to primary care centers 1.81 (95%CI: 1.14-2.86) were positively associated with CRCS utilization. On the other hand, being single was negatively associated with CRCS utilization. Conclusion: In this nationally representative sample CRCS prevalence was very low. According to our findings and in the context of the burden of colorectal cancer on the population, we recommend developing national evidence-based policies and programs that take in consideration easiness of transportation and the availability of primary care centers near to Saudi elderly population.

Patient Attitudes Toward Individualized Recommendations to Stop Low-Value Colorectal Cancer Screening

IMPORTANCE

Guidelines for colorectal cancer (CRC) screening recommend an individualized approach in older adults that is informed by consideration of life expectancy and cancer risk. However, little is known about how patients perceive individualized screening recommendations.

OBJECTIVE

To assess veterans' attitudes toward and comfort with cessation of low-value CRC screening (defined as screening in a patient for whom the benefit is expected to be small based on quantitative estimates from hypothetical risk calculators).

DESIGN, SETTING, AND PARTICIPANTS

This survey study included patients older than 50 years who had undergone prior screening colonoscopy with normal results at the Veterans Affairs Ann Arbor Healthcare System. A total of 1500 surveys were mailed to potential participants from November 1, 2010, to January 1, 2012. Survey data were analyzed from January 1, 2016, to December 31, 2017.

MAIN OUTCOMES AND MEASURES

Response to the question, "If you personally had serious health problems that were likely to shorten your life and your doctor did not think screening would be of much benefit based on the calculator, how comfortable would you be with not getting any more screening colonoscopies?"

RESULTS

Of the 1500 surveys mailed, 85 were returned to sender, leaving 1415 potential respondents; 1054 of these respondents (median age range, 60-69 years; 884 [85.9%] white and 965 [94.2%] male) completed the survey (response rate, 74.5%). A total of 300 (28.7%) were not at all comfortable with cessation of low-value CRC screening, and 509 (49.3%) thought that age should never be used to decide when to stop screening. In addition, 332 (31.7%) thought it was not at all reasonable to use life expectancy calculators, and 255 (24.3%) thought it was not at all reasonable to use CRC risk calculators to guide these decisions. In ordered logistic regression analysis, factors associated with more comfort with screening cessation were (1) higher trust in physician (odds ratio [OR], 1.19; 95% CI, 1.07-1.32), (2) higher perceived health status (OR, 1.41; 95% CI, 1.23-1.61), and (3) higher barriers to screening (OR, 1.20; 95% CI, 1.11-1.30). Factors that were associated with less comfort with screening cessation included (1) greater perceived effectiveness of screening (OR, 0.86; 95% CI, 0.80-0.94) and (2) greater perceived threat of CRC (OR, 0.81; 95% CI, 0.73-0.89).

CONCLUSIONS AND RELEVANCE

The findings suggest that many veterans have strong preferences against screening cessation even when given detailed information about why the benefit may be low. Efforts to tailor screening recommendations may be met by resistance unless they are accompanied by efforts to address underlying perceptions about the benefit of screening.

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

OBJECTIVES

Although the 2008 US Preventive Services Task Force guidelines recommend against routine colorectal cancer (CRC) screening for adults aged 76-85, it is unclear what endoscopists recommend in practice. Our goal was to examine current practice around cessation of CRC screening in older adults.

METHODS

We included normal screening colonoscopy exams in adults ≥ 50 years old within the New Hampshire Colonoscopy Registry between 2009 and 2014. The primary outcome was endoscopists' recommendation against further screening. The main exposure variables included patient age, family history of CRC, and endoscopist characteristics. Descriptive statistics and univariate and multivariable logistic regression models were used.

RESULTS

Of 13,364 normal screening colonoscopy exams, 2914 (21.8%) were in adults aged ≥ 65 and were performed by 74 endoscopists. Nearly 100% of adults aged 65-69 undergoing screening colonoscopy were given the recommendation to return for screening colonoscopy in the future. Only 15% of average-risk patients aged 70-74 were told to stop receiving screening, while 85% were told to return at a future interval, most frequently in 10 years when they would be 80-84. In the multivariable model, advancing patient age and the absence of family history of CRC were significantly associated with a recommendation to stop colonoscopy. Gastroenterologists were more likely to recommend stopping colonoscopy in accordance with guidelines than other non-gastroenterology endoscopists (adjusted OR (95% CI) 2.3 (1.6-3.4)).

CONCLUSIONS

In a large statewide colonoscopy registry, the majority of older adults are told to return for future screening colonoscopy. Having a family history of CRC or a non-gastroenterology endoscopist increases the likelihood of being told to return for screening at advanced ages.

Cancer and dementia: Two sides of the same coin?

Noncentral nervous system cancer and the brain share an interesting and complex relation, with an emerging body of evidence showing that cancer patients are at an increased risk of developing cognitive problems. In contrast, population-based studies consistently find an inverse link between cancer and dementia, that is patients with dementia having a lower risk of subsequently developing cancer, and cancer patients being less often diagnosed with dementia. Different biological processes such as inversely activated cell proliferation and survival pathways have been suggested to have an important role underlying this inverse association. However, the effect of methodological biases including surveillance or survival bias has not been completely ruled out, calling into question the inverse direction of the association between cancer and dementia. In fact, emerging evidence now suggests that cancer and dementia might share a positive association. This narrative review summarises the current literature on cancer, cognitive problems and dementia. Moreover, different strategies will be discussed to reduce the impact of potential methodological biases on the association between cancer and dementia, trying to reveal the true direction of this link.

A systematic review of the prevalence of comorbid cancer and dementia and its implications for cancer-related care

OBJECTIVES

A comorbid diagnosis of cancer and dementia (cancer-dementia) may have unique implications for patient cancer-related experience. The objectives were to estimate prevalence of cancer-dementia and related experiences of people with dementia, their carers and cancer clinicians including cancer screening, diagnosis, treatment and palliative care.

METHOD

Databases were searched (CINAHL, Psychinfo, Medline, Embase, BNI) using key terms such as dementia, cancer and experience. Inclusion criteria were as follows: (a) English language, (b) published any time until early 2016, (c) diagnosis of cancer-dementia and (d) original articles that assessed prevalence and/or cancer-related experiences including screening, cancer treatment and survival. Due to variations in study design and outcomes, study data were synthesised narratively.

RESULTS

Forty-seven studies were included in the review with a mix of quantitative (n = 44) and qualitative (n = 3) methodologies. Thirty-four studies reported varied cancer-dementia prevalence rates (range 0.2%-45.6%); the others reported reduced likelihood of receiving: cancer screening, cancer staging information, cancer treatment with curative intent and pain management, compared to those with cancer only. The findings indicate poorer cancer-related clinical outcomes including late diagnosis and higher mortality rates in those with cancer-dementia despite greater health service use.

CONCLUSIONS

There is a dearth of good-quality evidence investigating the cancer-dementia prevalence and its implications for successful cancer treatment. Findings suggest that dementia is associated with poorer cancer outcomes although the reasons for this are not yet clear. Further research is needed to better understand the impact of cancer-dementia and enable patients, carers and clinicians to make informed cancer-related decisions.

Exploring factors that might influence primary-care provider discussion of and recommendation for prostate and colon cancer screening

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.

A Decision Aid to Promote Appropriate Colorectal Cancer Screening among Older Adults: A Randomized Controlled Trial

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

Association between age factors and strategies for promoting participation in gastric and colorectal cancer screenings

Background

Despite the long history of cancer screening in Japan, the participation rates in gastric and colorectal cancer screenings have not increased. Strategies for improving the participation rates have been proposed, but differences in their effects among different age groups remain unclear.

Methods

The Japanese government conducted a national survey in all municipalities in Japan in 2010 to investigate whether the implementation of promotion strategies increased participation in cancer screening. We investigated the association between age factors and strategies for promoting participation in cancer screening based on this national survey. Multiple regression analysis with generalized linear model was performed using the participation rates in gastric and colorectal cancer screenings as dependent variables, and the following strategies for promoting participation as independent variables: 1) personal invitation letters, 2) household invitation letters, 3) home visits by community nurses, 4) screenings in medical offices, and 5) free cancer screening programs.

Results

One thousand six hundred thirty nine municipalities for gastric cancer screening and 1666 municipalities for colorectal cancer screening were selected for the analysis. In gastric and colorectal cancer screenings, the participation rates of individuals aged 60–69 years was higher than those of other age groups. Personal and household invitation letters were effective promotion strategies for all age groups, which encouraged even older people to participate in gastric and colorectal cancer screenings. Screening in medical offices and free screenings were not effective in all age groups. Home visits were effective, but their adoption was limited to small municipalities.

Conclusions

To clarify whether promotion strategies can increase the participation rate in cancer screening among different age groups, 5 strategies were assessed on the basis of a national survey. Although personal and household invitation letters were effective strategies for promoting participation in cancer screening for all age groups, these strategies equally encouraged older people to participate in gastric and colorectal cancer screenings. If resource for sending invitation letters are limited, priority should be given to individuals who are in their 50s and 60s for gastric and colorectal cancer screening.

Design of a randomized clinical trial of a colorectal cancer screening decision aid to promote appropriate screening in community-dwelling older adults

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.

Impact of comorbid conditions on participation in an organised colorectal cancer screening programme: a cross-sectional study

Background

There is controversy regarding how comorbidity impacts on colorectal cancer screening, especially in the context of organised programmes. The aim of this study is to assess the effect of comorbidities on participation in the Barcelona population-based colorectal cancer screening programme (BCCSP).

Methods

Cross-sectional study carried out in ten primary care centres involved in the BCCSP. Individuals aged 50 to 69, at average risk of colorectal cancer, who were invited to participate in the first round of the faecal immunochemical test-based BCCSP were included (2011–2012). The main variable was participation in the BCCSP. Comorbidity was assessed by clinical risk group status. Other adjusting variables were age, sex, socioeconomic deprivation, visits to primary care, smoking, alcohol consumption and body mass index. Logistic regression models were used to test the association between participation in the programme and potential explanatory variables. The results were given as incidence rate ratios (IRR) and their 95% confidence intervals (CI).

Results

Of the 36,208 individuals included, 17,404 (48%) participated in the BCCSP. Participation was statistically significantly higher in women, individuals aged 60 to 64, patients with intermediate socioeconomic deprivation, and patients with more medical visits. There was a higher rate of current smoking, high-risk alcohol intake, obesity and individuals in the highest comorbidity categories in the non-participation group. In the adjusted analysis, only individuals with multiple minor chronic diseases were more likely to participate in the BCCSP (IRR 1.14; 95% CI [1.06 to 1.22]; p < 0.001). In contrast, having three or more dominant chronic diseases was associated with lower participation in the screening programme (IRR 0.76; 95% CI [0.65 to 0.89]; p = 0.001).

Conclusions

Having three or more dominant chronic diseases, was associated with lower participation in a faecal immunochemical test-based colorectal cancer screening programme, whereas individuals with multiple minor chronic diseases were more likely to participate. Further research is needed to explore comorbidity as a cause of non-participation in colorectal cancer screening programmes and which individuals could benefit most from colorectal cancer screening.

Colon Cancer Screening among Patients Receiving Dialysis in the United States: Are We Choosing Wisely?

The American Society of Nephrology recommends against routine cancer screening among asymptomatic patients receiving maintenance dialysis on the basis of limited survival benefit. To determine the frequency of colorectal cancer screening among patients on dialysis and the extent to which screening tests were targeted toward patients at lower risk of death and higher likelihood of receiving a kidney transplant, we performed a cohort study of 469,574 Medicare beneficiaries ages ≥50 years old who received dialysis between January 1, 2007 and September 30, 2012. We examined colorectal cancer screening tests according to quartiles of risk of mortality and kidney transplant on the basis of multivariable Cox modeling. Over a median follow-up of 1.5 years, 11.6% of patients received a colon cancer screening test (57.9 tests per 1000 person-years). Incidence rates of colonoscopy, flexible sigmoidoscopy, and fecal occult blood test were 27.9, 0.6, and 29.5 per 1000 person-years, respectively. Patients in the lowest quartile of mortality risk were more likely to be screened than those in the highest quartile (hazard ratio, 1.53; 95% confidence interval, 1.49 to 1.57; 65.1 versus 46.4 tests per 1000 person-years, respectively), amounting to a 33% higher rate of testing. Additionally, compared with patients least likely to receive a transplant, patients most likely to receive a transplant were more likely to be screened (hazard ratio, 1.68; 95% confidence interval, 1.64 to 1.73). Colon cancer screening is being targeted toward patients on dialysis at lowest risk of mortality and highest likelihood of transplantation, but absolute rates are high, suggesting overscreening.

Barriers and facilitators associated with colonoscopy completion in individuals with multiple chronic conditions: a qualitative study

BACKGROUND

A recommendation to undergo a colonoscopy, an invasive procedure that requires commitment and motivation, planning (scheduling and finding a driver) and preparation (diet restriction and laxative consumption), may be uniquely challenging for individuals with multiple chronic conditions (MCCs). This qualitative study aimed to describe the barriers and facilitators to colonoscopy experienced by such patients.

MATERIALS AND METHODS

Semistructured focus groups were conducted with male Veterans who were scheduled for outpatient colonoscopy and either failed to complete the procedure or completed the examination. Focus group recordings were transcribed and analyzed by an inductive grounded approach using constant comparative analysis.

RESULTS

Forty-four individuals aged 51-83 years participated in this study (23 adherent and 21 nonadherent). Participants had an average of 7.4 chronic conditions (range 2-14). The five most common chronic conditions were hypertension (75%), hyperlipidemia (75%), osteoarthritis/degenerative joint disease (59%), atherosclerotic heart disease (48%), and diabetes mellitus (36%). We identified four unique themes that influenced motivation to undergo a colonoscopy: competing medical priorities, low perceived benefit, a prior negative colonoscopy experience, and pre-existing medical conditions. Additionally, we identified four themes that influenced individuals' ability to complete the examination: difficulty with bowel cleansing, difficulty with travel, worry about exacerbation of pre-existing conditions, and heightened concerns about potential complications.

CONCLUSION

MCCs are common in individuals referred for colonoscopy and generate unique barriers to colonoscopy completion related to medication, dietary changes, transportation, preparation processes, symptoms exacerbation, and complication concerns. Future research should examine whether tailored interventions that include education and support in addressing the unique barriers can enhance colonoscopy completion.

Decreased Risk of Colorectal Cancer after Colonoscopy in Patients 76-85 Years Old in the United States

BACKGROUND/AIMS

The benefits of colonoscopy in reducing colorectal cancer (CRC) risk for patients over 75 years are controversial. We aimed to determine whether colonoscopy use is associated with a decreased risk of CRC in patients 76-85 years old in the United States (US).

PATIENTS AND METHODS

All patients in the Medicare 5% random sample of the Surveillance, Epidemiology and End Results-Medicare linked database 76-85 years old at outpatient colonoscopy between January 1, 1998 and December 31, 2002 were identified. Using the Kaplan-Meier method, we estimated the cumulative incidence of CRC in the above-mentioned colonoscopy group and compared with the control group of patients without colonoscopy. All patients were followed until diagnosis of CRC or carcinoma in situ, death or December 31, 2005. The multivariate Cox proportional hazards model was used in statistical analysis. CRC was separated by location into distal vs. proximal CRC in subgroup analysis.

RESULTS

Of 5,701 patients in the colonoscopy group, 37 (0.65%) patients were diagnosed with CRC, compared to 379 (1.55%) out of 24,437 patients in the control group (p < 0.001). The cumulative incidences of distal and proximal CRC were lower in the colonoscopy group compared to those in the control group (5-year distal CRC: 0.26 vs. 0.77%; 5-year proximal CRC: 0.43 vs. 0.79%, both p < 0.05). In multivariate Cox regression, colonoscopy was associated with decreased risk of all CRC (hazard ratio ((HR) 0.42, 95% CI 0.28-0.65), distal CRC (HR 0.36, 95% CI 0.18-0.70), and proximal CRC (HR 0.53, 95% CI 0.30-0.92)).

CONCLUSION

Among patients 76-85 years old in the United States, colonoscopy use was associated with decreased risks of both distal and proximal CRC, with a smaller risk reduction in distal colon. Due to inherent limitations associated with our retrospective design, future prospective studies are needed to validate these findings.

Quality assurance manual of endoscopic screening for gastric cancer in Japanese communities

The Japanese government introduced endoscopic screening for gastric cancer in 2015 as a public policy based on the Japanese guidelines on gastric cancer screening. To provide appropriate endoscopic screening for gastric cancer in Japanese communities, we developed a quality assurance manual of endoscopic screening and recommend 10 strategies with their brief descriptions as follows: (i) Formulation of a committee responsible for implementing and managing endoscopic screening, and for deciding the suitable implementation methods in consideration of the local context; (ii) Development of an interpretation system that leads to a final judgement to standardize endoscopic examination and improve its accuracy; (iii) Preparation of management and reporting systems for adverse effects by the committee for safety management; (iv) Obtaining informed consent before operation following adequate explanations regarding the benefits and harms of endoscopic screening; (v) Avoidance of frequent screenings to reduce false-positive results and overdiagnosis. As a reference, the target age group is ≥50 years, and the screening interval is 2 years; (vi) Keeping the biopsy rate within 10% as post-biopsy bleeding may occur. Before endoscopic screening, any history of antithrombotic drug usage should be checked; (vii) Nonadministration of sedation in endoscopic screening for safety management; (viii) Adherence to proper endoscopic cleaning and disinfection to reduce infection; (ix) Use of a checklist to achieve optimal program preparation when municipal governments introduce endoscopic screening; (x) Identification of the aims and roles by referring to a checklist if primary care physicians decide to participate in endoscopic screening.

Quality of End-of-Life Care Provided to Patients With Different Serious Illnesses

IMPORTANCE

Efforts to improve end-of-life care have focused primarily on patients with cancer. High-quality end-of-life care is also critical for patients with other illnesses.

OBJECTIVE

To compare patterns of end-of-life care and family-rated quality of care for patients dying with different serious illnesses.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cross-sectional study was conducted in all 146 inpatient facilities within the Veteran Affairs health system among patients who died in inpatient facilities between October 1, 2009, and September 30, 2012, with clinical diagnoses categorized as end-stage renal disease (ESRD), cancer, cardiopulmonary failure (congestive heart failure or chronic obstructive pulmonary disease), dementia, frailty, or other conditions. Data analysis was conducted from April 1, 2014, to February 10, 2016.

MAIN OUTCOMES AND MEASURES

Palliative care consultations, do-not-resuscitate orders, death in inpatient hospices, death in the intensive care unit, and family-reported quality of end-of-life care.

RESULTS

Among 57 753 decedents, approximately half of the patients with ESRD, cardiopulmonary failure, or frailty received palliative care consultations (adjusted proportions, 50.4%, 46.7%, and 43.7%, respectively) vs 73.5% of patients with cancer and 61.4% of patients with dementia (P < .001). Approximately one-third of patients with ESRD, cardiopulmonary failure, or frailty (adjusted proportions, 32.3%, 34.1%, and 35.2%, respectively) died in the intensive care unit, more than double the rates among patients with cancer and those with dementia (13.4% and 8.9%, respectively) (P < .001). Rates of excellent quality of end-of-life care reported by 34 005 decedents' families were similar for patients with cancer and those with dementia (adjusted proportions, 59.2% and 59.3%; P = .61), but lower for patients with ESRD, cardiopulmonary failure, or frailty (54.8%, 54.8%, and 53.7%, respectively; all P ≤ .02 vs patients with cancer). This quality advantage was mediated by palliative care consultation, setting of death, and a code status of do-not-resuscitate; adjustment for these variables rendered the association between diagnosis and overall end-of-life care quality nonsignificant.

CONCLUSIONS AND RELEVANCE

Family-reported quality of end-of-life care was significantly better for patients with cancer and those with dementia than for patients with ESRD, cardiopulmonary failure, or frailty, largely owing to higher rates of palliative care consultation and do-not-resuscitate orders and fewer deaths in the intensive care unit among patients with cancer and those with dementia. Increasing access to palliative care and goals of care discussions that address code status and preferred setting of death, particularly for patients with end-organ failure and frailty, may improve the overall quality of end-of-life care for Americans dying of these illnesses.

The impact of comorbidity on cancer and its treatment

Answer questions and earn CME/CNE Comorbidity is common among cancer patients and, with an aging population, is becoming more so. Comorbidity potentially affects the development, stage at diagnosis, treatment, and outcomes of people with cancer. Despite the intimate relationship between comorbidity and cancer, there is limited consensus on how to record, interpret, or manage comorbidity in the context of cancer, with the result that patients who have comorbidity are less likely to receive treatment with curative intent. Evidence in this area is lacking because of the frequent exclusion of patients with comorbidity from randomized controlled trials. There is evidence that some patients with comorbidity have potentially curative treatment unnecessarily modified, compromising optimal care. Patients with comorbidity have poorer survival, poorer quality of life, and higher health care costs. Strategies to address these issues include improving the evidence base for patients with comorbidity, further development of clinical tools to assist decision making, improved integration and coordination of care, and skill development for clinicians. CA Cancer J Clin 2016;66:337-350. © 2016 American Cancer Society.

Patterns of Care for Colorectal Liver Metastasis Within an Integrated Health System: Secular Trends and Outcomes

BACKGROUND

Utilization of evidence-based treatments for patients with colorectal liver metastasis (CRC-LM) outside high-volume centers is not well-characterized. We sought to describe trends in treatment and outcomes, and identify predictors of therapy within a nationwide integrated health system.

METHODS

Observational cohort study of patients with CRC-LM treated within the Veterans Affairs (VA) health system (1998-2012). Secular trends and outcomes were compared on the basis of treatment type. Multivariate regression was used to identify predictors of no treatment (chemotherapy or surgery).

RESULTS

Among 3270 patients, 57.3 % received treatment (chemotherapy and/or surgery) during the study period. The proportion receiving treatment doubled (38 % in 1998 vs. 68 % in 2012; trend test, p < 0.001), primarily driven by increased use of chemotherapy (26 vs. 57 %; trend test, p < 0.001). Among patients having surgery (16 %), the proportion having ablation (10 vs. 61.9 %; trend test, p < 0.001) and multimodality therapy (15 vs. 67 %; trend test, p < 0.001) increased significantly over time. Older patients [65-75 years: odds ratio (OR) 1.65, 95 % confidence interval (CI) 1.39-1.97; >75 years: OR 3.84, 95 % CI 3.13-4.69] and those with high comorbidity index (Charlson ≥3: OR 1.47, 95 % CI 1.16-1.85) were more likely to be untreated. Overall survival was significantly different based on treatment strategy (log-rank p < 0.001).

CONCLUSIONS

The proportion of CRC-LM patients receiving treatment within the largest integrated health system in the US (VA health system) has increased substantially over time; however, one in three patients still does not receive any treatment. Future initiatives should focus on increasing treatment among older patients as well as on evaluating reasons leading to the no-treatment approach and increased use of ablation procedures.

Assessing Colorectal Cancer Screening Adherence of Medicare Fee-for-Service Beneficiaries Age 76 to 95 Years

INTRODUCTION

There are concerns about potential overuse of colorectal cancer (CRC) screening services among average-risk individuals older than age 75 years.

MATERIALS AND METHODS

Using a 5% random noncancer sample of Medicare beneficiaries who resided in the SEER areas, we examined rates of CRC screening adherence, defined by the Medicare coverage policy, among average-risk fee-for-service beneficiaries age 76 to 95 years from 2002 to 2010. The two outcomes are the status of overall CRC screening adherence, and the status of adherence to colonoscopy (v other modalities) conditional on patient adherence.

RESULTS

Overall CRC screening adherence rates of Medicare beneficiaries age 76 to 95 years increased from 13.0% to 21.4% from 2002 to 2010. In 2002, 2.2% of beneficiaries were adherent to colonoscopy, and 10.7%, by other modalities; the corresponding rates were 19.5% and 1.9%, respectively, in 2010. Specifically, rates of adherence to colonoscopy were 1.1% for those age 86 to 90 years and almost nil for those age 91 to 95 years in 2002, but the rates became 13.5% and 8.2%, respectively, in 2010. Compared with white beneficiaries, black beneficiaries age 76 to 95 years had a 7-percentage-point lower adherence rate. However, overall adherence rates among blacks increased by 168.6% from 2002 to 2010, whereas rates among whites increased by 63.0%. Logistic regressions showed that blacks age 86 to 95 years were less likely than whites to be adherent (odds ratio, 0.56; 95% CI, 0.47 to 0.59) but were more likely to be adherent to colonoscopy (odds ratio, 2.34; 95% CI, 1.47 to 3.91).

CONCLUSION

High proportions of average-risk Medicare fee-for-service beneficiaries screened by colonoscopy may represent opportunities for improving appropriateness and allocative efficiency of CRC screening by Medicare.