Gaps in CRC Screening in Seniors

Action Points

  • More than a fourth of healthy older patients did not have up-to-date screening for colorectal cancer (CRC), and a third of those with a positive fecal blood tests did not have timely follow-up.
  • Note that clinical guidelines uniformly recommend CRC screening for adults 50 to 75 but no consensus exists with regard to CRC screening in older patients.

More than a fourth of healthy older patients did not have up-to-date screening for colorectal cancer (CRC), and a third of those with a positive fecal blood tests did not have timely follow-up, an analysis of three large integrated health plans showed.

The proportion of patients with current screening and timely follow-up for positive tests was significantly lower in the subgroup ≥76 (P<0.001). Age influenced screening practices more so than comorbidities, particularly with respect to meeting current screening recommendations. Across all agree groups from 65 to 89, the likelihood of timely follow-up decreased significantly as comorbidities increased (P<0.001).

The age- and comorbidity-related decline in timely followup after an abnormal test result is “especially concerning, because the elderly patients in this study were all insured members of integrated healthcare systems with comprehensive patient tracking, advice, and proactive scheduling of colonoscopy appointments that many small primary care practices lack,” Carrie N. Klabunde, PhD, of the National Institutes of Health Office of Disease Prevention in Rockville, Md., and co-authors wrote in an article published online in the American Journal of Preventive Medicine.

The findings “suggest a need for reevaluating age-based screening guidelines and improving screening completion among the elderly,” they added.

Clinical guidelines uniformly recommend CRC screening for adults 50 to 75 to reduce the risk of CRC mortality. In contrast, no consensus exists with regard to CRC screening in older patients, as the U.S. Preventive Services Task Force, U.S. Multisociety Task Force, and American College of Physicians have differing positions on the issue.

The American Geriatrics Society has recommended an individualized approach to CRC screening that is not defined strictly by age. Several recent studies have provided support for individualized screening, suggesting that healthy patients >75 may benefit from screening, Klabunde and authors noted.

However, during the time period of the study, the USPSTF flatly recommended against screening for individuals older than 85, and discouraged it for those 76-85 unless they had special risk factors. The pattern of screening by age found in the current study generally matched those recommendations.

To examine the impact of age and comorbidities on CRC screening and follow-up, Klabunde and colleagues analyzed data for 846,267 older patients enrolled in three integrated health plans during 2011 and 2012. The outcomes of interest were up-to-date CRC screening (fecal occult blood test [FOBT] or fecal immunochemical testing [FIT] within the past 24 months, sigmoidoscopy in the past 5 years, or colonoscopy in the past 10 years) and timely follow-up of abnormal FOBT or FIT (colonoscopy within 3 months).

Patients 65 to 75 accounted for 64% of the study population, followed by 76 to 84 (28%), and 85 to 89 (8%). Comorbidities were defined by the Charlson index. Half the patient had a Charlson score of 0, and 20.4% had a comorbidity score of 1. About 10% had a Charlson score ≥4.

Overall, 72% of study members were up-to date with CRC screening: 63.3% of patients 65 to 69, 86% of those 70to 75, 55.4% of those 76 to 84, and 32% of those 85 to 89. Among patients who were up to date, the most recent screening test was FOBT or FIT testing in 38.1%, colonoscopy in 35.9%, sigmoidoscopy in 8.1%, and combination testing in 18.0%.

The authors found that 8.5% of patients tested by FOBT or FIT had positive results. Of those with positive tests, 64.9% had follow-up colonoscopy within 3 months.

“In most other practice settings in the U.S., I would expect colorectal cancer screening and follow up rates to be lower … a hypothesis that is supported by nationally representative data from the National Health Interview Survey,” Klabunde told MedPage Today.

The findings highlight the issue of appropriate selection of aging patients for screening, as well as the “considerable need for informed discussions between physicians and patients, and individualized screening decisions, because the relative harms and potential benefits of screening change with increasing age and comorbidity,” she added.

The progression from benign colonic polyp to adenoma to symptomatic malignancy often occurs over many years, complicating decision making about CRC screening in older patients.

“In deciding whether to offer screening at all to older patients and in helping them decide whether or not to get screened, consideration of quality life expectancy is key,” said Richard Wender, chief cancer control officer for the American Cancer Society. Development of a “health-adjusted age” or other individualized screening-decision model might be helpful to primary care clinicians, who often struggle with estimating life expectancy and do not routinely use available tools.

CRC screening needs for older patients notwithstanding, “most of the missed screening opportunities are actually in pre-Medicare populations, particularly those with no health insurance, Medicaid, or relative under-insurance,” Wender noted.

Klabunde and co-authors acknowledged several limitations of the study, notably, lack of information on patient preferences for CRC screening, functional limitations, and family history of CRC.

This work was supported by the National Cancer Institute.

The authors declared they had no potential conflicts of interest with respect to the research.

  • Reviewed by
    Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

last updated 06.30.2016

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