Surveillance colonoscopy ‘may be overutilized’ in older adults with lower life expectancy
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Key takeaways:
- Most patients were advised to return for future colonoscopy, regardless of life expectancy or if current findings were clinically insignificant.
- Results may provide guidance to stop or continue colonoscopy.
Despite a low likelihood of finding advanced polyps or colorectal cancer, more than 85% of older patients with a history of polyps were advised to return for surveillance colonoscopy, regardless of life expectancy or current results.
“We have observed in clinical care that colonoscopy for monitoring in patients with a history of colon polyps is sometimes performed when people are of advanced age and/or when people may not be in the best health due to other medical problems or have competing health priorities,” Audrey H. Calderwood, MD, MS, director of the Comprehensive Gastroenterology Center and associate professor at Geisel School of Medicine and the Dartmouth Institute, told Healio. “Another motivation was the current lack of data to help clinicians and their patients decide on whether or not pursuing another colonoscopy in the context of their overall health is the right decision for them.”
She continued: “Our prior work talking to older adults with polyps about this topic is that they want to be involved in decision-making and to better understand the benefits and risks.”
Using data from the linked New Hampshire Colonoscopy Registry Medicare Claims database, Calderwood and colleagues evaluated the association between estimated life expectancy and surveillance colonoscopy findings and follow-up recommendations in 9,831 adults (mean age, 73.2 years; 53.8% men) who underwent colonoscopy following prior polyp detection between April 2009 and December 2018.
According to results published JAMA Internal Medicine, 57.5% of participants had an estimated life expectancy of at least 10 years, 35% of 5 to 10 years and 7.5% of less than 5 years. Self-reported assessments of fair or poor health increased as estimated life expectancy decreased (6.2%, 9.6% and 21.8%, respectively) and age “strong correlated” with estimated life expectancy.
While most participants (85.3%) had no significant findings or one to two small adenomas or serrated polyps, 7.8% had advanced polyps and 0.2% had CRC.
Of the 5,281 participants who had a recommendation to stop or continue future colonoscopy, 86.9% were advised to return for future colonoscopy even without significant colonoscopy findings or limited life expectancy.
“This suggests that colonoscopy may be overutilized in this demographic,” Calderwood noted.
Further, longer life expectancy was associated with a recommendation to return for future colonoscopy regardless of clinical findings (life expectancy 10 years: adjusted OR = 21.5; 95% CI, 15.2-30.3; 5 to < 10 years: aOR = 2.7; 95% CI, 2-3.6). For example, in patients with no polyps or few small polyps, 58.1% with life expectancy of less than 5 years were advised to return for future surveillance colonoscopy compared with 74.8% with life expectancy of 5 to 10 years and 95.2% with life expectancy of at least 10 years.
Researchers also reported that within each category of life expectancy, the frequency of follow-up colonoscopy increased with the severity of findings.
These findings could help clinicians tailor their recommendations for surveillance colonoscopy in older adults, Calderwood told Healio.
“For example, if someone’s life expectancy is less than 5 years, a recommendation against surveillance makes sense, because that person is unlikely to benefit from the colonoscopy and therefore the minimal but potential harms of surveillance colonoscopy outweigh the benefits,” she said.
“On the other hand, if the future health of a patient is unknown, it would make sense for clinicians to avoid providing definitive recommendations for future colonoscopy. This would allow for flexibility to make a more informed decision around benefit and risk when the time comes several years down the road when their health status at the time is known.”
Perspective
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Maged K. Rizk, MD, MBA
My colleagues and I reported similar observations in a study published in JAMA Internal Medicine that looked at colonoscopy in individuals aged older than 75 years. The findings showed that in patients in this age group, a large proportion of screening colonoscopies were among those with limited life expectancy (< 10 years), which was associated with an increased risk for complications.
While society recommendations are that care should be individualized for patients after the age of 75 years based on comorbidities and life expectancy, real-life application has been difficult. Tools that help providers become more proscriptive may be required to have conversations with patients around the need for continued colon cancer surveillance and its benefits.
Reference:
El Halabi J, et al. JAMA Intern Med. 2023;doi:10.1001/jamainternmed.2023.0435.
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