Continuation of Screening Endoscopy for Colorectal Cancer in Older Adults

Abstract

Colorectal cancer is not only one of the most common, but also one of the most preventable cancers globally. Screening for colorectal cancer has been associated with reduced diseasespecific mortality through detection of cancer at earlier stages, as well as through detection and removal of its precursor lesions.While most professional guidelines recommend routine screening of asymptomatic adults older than 50 years for colorectal cancer, there is disagreement on the age to stop screening. For example, the US Preventive Services Task Force (USPSTF) and the American College of Gastroenterology recommend screening until age 75 years, followed by individualized decision-making for people older than 75 years. 1,2 In contrast, the Canadian Task Force on Preventive Health does not recommend screening adults 75 years and older for colorectal cancer. 3 Likewise, the Asia Pacific Colorectal Cancer Working Group recommends 75 years as a reasonable age limit to stop screening. 4 Nonetheless, these recommendations were largely made based on evidence from modeling studies 5 and indirect evidence, such as reduced life expectancy in older individuals, and disparate inclusion of older adults in colorectal cancer screening trials. 3 Amid the scant empirical data on when best to stop offering colorectal cancer screening, in this issue of JAMA Oncology, Ma et al 6 examine the association between lower endoscopy (colonoscopy and sigmoidoscopy) and the risk of colorectal cancer, as well as its mortality in older adults (older than 75 years). By performing a robust analysis of data from 2 large prospective cohort studies, the Nurses' Health Study and the Health Professionals Follow-up Study, the authors have demonstrated that irrespective of prior endoscopic screening history, screening via colonoscopy or sigmoidoscopy after age 75 years was associated with significantly lower incidence of colorectal cancer (multivariable hazard ratio [HR], 0.61; 95% CI, 0.51-0.74) and colorectal cancer-related mortality (HR, 0.60; 95% CI, 0.46-0.78). It was also reported that no survival benefit was observed with screening endoscopy after age 75 years in participants who had cardiovascular disease (HR, 1.18; 95% CI, 0.59-2.35) or significant comorbidities (HR, 1.17; 95% CI, 0.57-2.43). Therefore, this study appears to address a widely debated topic by providing empirical evidence that points toward a reduction in risk of colorectal cancer, as well as a survival gain associated with screening colonoscopy or sigmoidoscopy in individuals older than 75 years who have no substantial comorbidities, regardless of whether they have undergone prior endoscopic screening.

Prevalence of colorectal cancer screening test use by test type and age among older adults in the United States

“…Given the elevated risk of colonoscopy harms among older adults, including post colonoscopy bleeding, 7 several experts have called for increased consideration of stool testing among adults aged 76 years and older. 7,8 Our study found stool testing was less common than colonoscopy among older Americans in 2019, and CT colonography and flexible sigmoidoscopy were rarely used. These patterns by test type mirror 2018 test use patterns reported for US adults aged 50-75 years.…”

“…The AG cases have recently had substantial growth in use by non-MD students 8 especially by Doctor of Osteopathy (DO) students, IM and FM residents, Geriatrics Fellows, and NP and PA students. This letter describes the extent and pattern of use of AG cases and the level of satisfaction stratified by discipline, to inform the growth of AG to be inclusive of the various HP students' professional competencies.…”

Optimizing Colorectal Cancer Screening Strategies and Target Populations in Budget-Constrained Regions through Cost-Effectiveness Analysis: A Case from China's East

“…As the program is implemented, screening strategies for younger populations can be further optimized. Similarly, for the elderly population, the incidence of adverse events from colonoscopy increases, and the bene ts of screening are controversial, which may require more personalized approaches 25 .…”