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

Abstract

VoLuME 113 | dEcEMBEr 2018 Background Colorectal cancer (CRC) is the second leading cause of cancer death in men and women in the United States (US). Because of the effectiveness of CRC screening in reducing the incidence of and mortality associated with CRC, ample research has focused on improving adherence to screening for CRC [1-3]. The "de-escalation" of screening, meaning the cessation of routine preventive screening in older adults when benefits may be minimal or outweighed by potential risks, is an emerging concept that will have increasing importance as the US population ages [4, 5]. Optimizing appropriate use of screening colonoscopy in older adults improves care at the patient level, and importantly, at the system level, it may reduce costs and improve availability of colonoscopy for those in need of first-time screening. In 2008, the US Preventive Services Task Force (USPSTF) recommended that routine CRC screening stops after the age of 75 and that the decision to screen be individualized between the ages of 76 and 85 [6]. At that time, the USPSTF also recommended against routine screening in adults over 85 years old. Similarly, the US Multi-Society Task Force (USMSTF) on CRC recommends that persons who are up-to-date with screening and have negative prior screening tests be considered to stop screening at the age of 75 years [7]. In addition, the USMSTF recommends

Physician Decision-Making About Surveillance in Older Adults With Prior Adenomas: Results From a National Survey

“…Prior studies on overuse in general have found that specialists were more likely to overuse tests and procedures, and several studies have found overuse of surveillance colonoscopies among gastroenterologists in the form of repeating surveillance earlier than recommended by guidelines (20,29–31). One study on screening colonoscopies among 74 endoscopists in a single state did find that gastroenterologists were more likely to recommend stopping screening colonoscopies in older adults than surgeons or family medicine endoscopists and attributed the finding to gastroenterologists' greater familiarity with guidelines (32), but because there is no clear guideline on stopping surveillance colonoscopies, this is not applicable to explain our finding. One possible explanation is that because the gastroenterologists are more likely to be performing the colonoscopies and being primarily responsible for related complications, they may be better attuned to the potential harms and therefore be more conservative in recommending colonoscopies.…”

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

“…Prior work using NHCR has shown that both family history of CRC and endoscopist specialty were associated with receiving a recommendation to screening colonoscopy. 11 Understanding when and how to stop colonoscopy for indications other than screening, such as surveillance of prior polyps and for evaluation of symptoms, is important as colonoscopy is performed more commonly in older adults for these indications than screening. In terms of guidance on stopping surveillance, the 2012 USMSTF guidelines recommend that "the decision to continue surveillance should be individualized, based on assessment of benefit, risk, and comorbidities," without listing specific ages for stopping.…”

“…Analyses using NHCR data have addressed many aspects of colonoscopy, including lifestyle factors associated with polyps, 12 adenoma and serrated polyp detection rates, 13,14 bowel preparation quality, 15,16 and outcomes in young adults 10 . However, NHCR studies focusing on older adults have been limited to a screening population without polyps 11 . Our goal is to provide a more comprehensive evaluation of colonoscopy use and outcomes across all indications (screening, surveillance, diagnostic) in older adults.…”

“…10 However, NHCR studies focusing on older adults have been limited to a screening population without polyps. 11 Our goal is to provide a more comprehensive evaluation of colonoscopy use and outcomes across all indications (screening, surveillance, diagnostic) in older adults. Low rates of clinically significant findings in older adults attending routine colonoscopy for screening or surveillance purposes could indicate overuse of colonoscopy, meriting improved assessment of patient age, risk factors, and previous colonoscopy findings in making decisions about whether to pursue colonoscopy.…”

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

“…The NHCR is a statewide registry that collects data from endoscopy sites performing colonoscopy throughout New Hampshire. [11][12][13] Prior to colonoscopy, patients complete a self-administered questionnaire on demographic factors, personal history of polyps and CRC, and family history of CRC.…”