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

Abstract

ImportanceSurveillance 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.ObjectiveTo evaluate the association of estimated life expectancy with surveillance colonoscopy findings and follow-up recommendations among older adults.Design, Setting, and ParticipantsThis 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.ExposuresLife expectancy (<5 years, 5 to <10 years, or ≥10 years), estimated using a validated prediction model.Main Outcomes and MeasuresThe main outcomes were clinical findings of colon polyps or colorectal cancer (CRC) and recommendations for future colonoscopy.ResultsAmong 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 RelevanceIn 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.

Colorectal Cancer Screening Receipt Does Not Differ by 10-Year Mortality Risk Among Older Adults

“…However, we observed no association between 10-year mortality risk and CRC screening, suggesting that in current practice, decisions and quality metrics remain anchored in chronological age (11). Similarly, in a large cohort study, more than half of adults with less than 5 years' life expectancy were recommended to return for future colonoscopy despite a low screening yield (15). Another important observation is that the prevalence of invasive screening paradoxically increased with lowered life expectancy among adults aged 70–79 years.…”

“…Relying on chronological age alone can lead to both overscreening (e.g., colonoscopy in a 74-year-old man with multiple chronic conditions) and underscreening (e.g., no screening in a healthy 76-year-old woman without chronic conditions). These scenarios underscore the importance of incorporating life expectancy and chronic conditions when considering CRC screening (13–16).…”

“…Relying on chronological age alone can lead to both overscreening (e.g., colonoscopy in a 74-yearold man with multiple chronic conditions) and underscreening (e.g., no screening in a healthy 76-year-old woman without chronic conditions). These scenarios underscore the importance of incorporating life expectancy and chronic conditions when considering CRC screening (13)(14)(15)(16). We used the National Health Interview Survey (NHIS) (17) to 1) estimate the prevalence of and factors associated with CRC screening among older adults aged 65-84 years who were not upto-date on CRC screening according to predicted 10-year mortality risk and 2) examine the proportion of screening performed among adults with life expectancy ,10 years, defined as 10-year mortality risk $50%.…”

Surveillance Colonoscopy Findings in Older Adults With a History of Colorectal Adenomas

“…Adenomas are found in nearly 40% of screening colonoscopies in the US, and after removal (polypectomy), guidelines recommend that patients undergo future surveillance colonoscopy . However, guidelines provide little direction regarding the age at which colonoscopy surveillance is unlikely to be of substantial benefit and could be stopped . Given the increasing aging population in the US and that nearly 5.6 million adults older than 75 years will undergo surveillance annually by 2024, estimating the yield of surveillance colonoscopy is important for understanding the balance between potential benefits and known risks of colonoscopy with advancing age.…”

“…The risks of colonoscopy increase with age, particularly among those aged 75 years or older, and include heart attack, stroke, sedation-related adverse events (eg, aspiration pneumonia), bleeding, infection, and perforation . In addition, the benefits of surveillance colonoscopy in older adults may be reduced because of a more limited life expectancy . Also, in many settings, colonoscopy demand exceeds capacity, and therefore, it is important to direct procedures to those for whom potential benefits will likely outweigh possible harms.…”