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Dear colleagues,
Colonoscopy is the bread and butter of endoscopy. Multidisciplinary updates continue to support screening colonoscopy in reducing the risk of developing colorectal cancer. But there has been debate about the best uses of resources, especially with increased recognition of colorectal cancer (CRC) in younger patients, and successive guidelines lengthening the intervals for most surveillance colonoscopy.
In particular, when do we feel comfortable recommending cessation of surveillance colonoscopy especially in those who are 75-85 years old? Routine colonoscopy remains a very low-risk procedure even in older patients with multiple comorbidities.
In this issue of Perspectives, Dr. Petr Protiva and Dr. Mariam Naveed address this issue and provide differing perspectives on approaching surveillance colonoscopy in the elderly.
We welcome your thoughts on this issue on Twitter at @AGA_GIHN.
Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.
Striking a balance: Deciding the optimal age to cease surveillance for colorectal neoplasia
BY PETR PROTIVA, MD, MPH
The appropriate age to stop surveillance for colorectal neoplasia remains uncertain. Screening for average-risk individuals is typically stopped at age 75, but personalized screening with shared decision-making may continue until age 85.1 Evidence suggests that any survival benefit of screening past age 86 would be outweighed by the harm of screening and/or natural mortality. Nevertheless, determining the optimal age for surveillance in those with a history of neoplasia still poses some challenges. The issue is confounded as many clinicians use the terms “screening” and “surveillance” interchangeably. It should be noted that screening implies the individual is at average risk, while surveillance refers to those at elevated risk because of a personal history of colonic adenomas or cancer
Comorbidities and life expectancy
Despite recent staggering setbacks and a drop in the average life expectancy in the United States, the proportion of individuals older than 65 years old has been steadily increasing to a currently estimated 58.9 million – 16.8% of the U.S. population – and is projected to increase in the future.2 However, the prevalence of comorbidities also increases with age, and these are crucial factors to weigh in the decision-making process. Severe comorbid conditions, such as chronic obstructive pulmonary disease, cirrhosis, chronic hepatitis, chronic renal failure, dementia, and congestive heart failure can limit a patient’s ability to undergo surveillance and diminish or negate its benefits. There are online tools that help clinicians estimate life expectancy and time to benefit (that is, time between the intervention and its benefit), such as the Lee or Schonberg index.3 Consensus on time to colorectal screening benefit is about 9-10 years, but may be much shorter for surveillance. Striking a balance between the potential benefits of continued surveillance and the risks and burdens imposed on older adults with limited life expectancy is essential for making well-informed decisions.
Age-related risk increase and risk of neoplasia in the surveillance population:
The absolute risk of developing colorectal cancer is dependent on age. In adults aged 45-49, it is 33.4/100,000, rising to 135.6 in those 70-74 years old; in persons aged 85 and older, it is 234.7/100,000.4 A significant challenge in determining the appropriate age to stop surveillance is the additional individual risk based on baseline polyp characteristics. It seems reasonable to treat low-risk adenomas similarly to screening and stop surveillance by 85 or 86 years old in most cases. The decision process is less clear in individuals with advanced lesions or a personal history of colon cancer. The prevalence of advanced adenomas on the baseline exam is about 15% and greater than 20% on the follow-up exam if the index adenoma(s) were at least 20 mm in diameter. For five or more adenomas at baseline, the prevalence of advanced lesions on follow-up exam is about 20%. On the other hand, a negative surveillance colonoscopy (that is, no polyps found) is associated with far fewer advanced lesions on follow-up.
Colonoscopy
The safety of colonoscopy in older adults should be considered. The colonoscopy procedure is generally very safe, but is associated with a higher risk of post-procedure complications after outpatient colonoscopy in patients 75 years and older. In addition, comorbidities such as anemia, cardiac arrhythmia, heart failure, hypertension, chronic kidney disease, liver disease, smoking history, and obesity are also risk factors. It should be noted that high-quality colonoscopy is key to the detection and full removal of neoplastic lesions and risk reduction. The inability to achieve adequate colon preparation for any reason or undertaking colonoscopy in patients at high risk for complications reduces its benefit.
Who should oversee surveillance, the primary care physician or gastroenterologist
Should a gastroenterologist oversee the decision on surveillance in older adults based on a combination of age, estimated procedure risk and benefits, patient preferences, and current guidelines? Certainly, it seems appropriate and that this is what most specialists think, according to a recent survey of gastroenterologists and primary care physicians (PCPs) on this topic.5 Perhaps, not surprisingly, most PCPs disagreed – PCPs are thoroughly familiar with their patients’ up-to-date comorbidities, functional status, and preferences, and they have the benefit of knowing them for a long time. They also integrate diagnostic results from multiple subspecialists, sometimes from different states. The role of PCPs is critical in centers that offer open-access colonoscopy. Gastroenterologists may be the most appropriate authority to evaluate older individuals for continued surveillance, but in most busy practices these patients are seen by mid-level practitioners. Specialists play an important role if the PCP is uncertain whether surveillance is still indicated or in older patients with a history of advanced adenoma. Therefore, the colonoscopy report or subsequent communication after pathology results are returned should include a recommendation for future surveillance and a clear provision for discontinuing the surveillance in case of future health decline.
Conclusion
Determining the optimal age to discontinue surveillance for colorectal neoplasia involves evaluating multiple factors. Although the age limit is clearer for average-risk screening and low-risk lesion surveillance, uncertainty remains for individuals with advanced neoplasia history. Significant factors in this decision-making process include subsequent neoplasia risk, comorbidities, life expectancy, and age-related risks associated with colonoscopy. Cooperation between PCPs and subspecialty physicians is essential in making surveillance decisions for older adults. PCPs are well positioned to consider detailed patient comorbidities, functional status, and patient preferences, especially with the help of online life-expectancy estimators for most elderly or comorbid patients. To assist in this process, gastroenterologists should state clearly in their procedure report and subsequent pathology letters whether surveillance is recommended and that it is conditional on future comorbidities and should be discontinued if the patient’s health significantly declines.
Dr. Protiva is associate professor of medicine, Yale University, and director of the colon cancer screening program, VA Connecticut Healthcare System, West Haven. Dr. Protiva has no relevant disclosures.
References
1. Patel SG et al. Gastroenterology. 2022;162:285-99
2. U.S. Census Bureau. Measuring America’s People, Places, and Economy
3. University of California, San Francisco. ePrognosis. 4. Siegel RL et al. CA Cancer J Clin. 2023 May-Jun;73(3):233-54.
5. Schoenborn NL et al. Am J Gastroenterol. 2023; 118(3):523-30.
The gastroenterologist should guide the decision to maintain, or halt, surveillance in older adults
BY MARIAM NAVEED, MD
Endoscopic screening and surveillance for CRC in older adults (≥ 75 years old) is a medical “gray area” that needs more high-quality data to inform clinical decision making. In the most recent 2022 clinical guideline update from the U.S. Multisociety Task Force on Colorectal Cancer, the recommendation to stop CRC screening in average risk patients older than 86 years is well supported because of colonoscopy-associated mortality risk outweighing the benefits of adenoma detection and removal. By comparison, screening recommendations for average risk individuals between 76-85 years old are ambiguous and ultimately the decision to proceed with colonoscopy in this clinical population should be individualized based on shared decision making between the provider and patient. Of note, the same guideline provides no specific guidance for ongoing surveillance in the same age group and similarly suggests a shared decision-making approach.1
As a practicing gastroenterologist in the retirement capital of Florida, older adults comprise a large portion of my clinical practice. I have noticed several aspects unique to this demographic that merit special consideration. For example, a significant percentage of these patients are seasonal (that is, “snowbird”) patients that have multiple sets of doctors (set of physicians in their home state and another set in Florida). Consequently, fragmentation of clinical data enables opportunities for colonoscopies to be wrongly ordered (either in an inappropriate time frame and/or for inaccurate indications). In my own practice, when such a patient is referred for consideration of CRC surveillance, any/all external records must first be obtained and validated as a prerequisite for appropriate clinical counseling and informed decision-making. Additionally, consideration of periprocedural risks is particularly relevant in older adults, secondary to both the increased rate of direct complications and the likelihood of pre-existing comorbidities affecting completion of a safe colonoscopy. Factors that can be easily overlooked include higher rates of poor bowel preparation and corresponding decreased completion rates. Moreover, if the patient has a history of high-risk adenomas or worrisome family history warranting ongoing evaluation, but they also have high-risk comorbidities, I will frequently involve the patient’s cardiologist or pulmonologist to provide medical clearance prior to offering CRC screening/surveillance.
In addition to the clinical ambiguity of appropriateness of continued CRC screening/surveillance in the setting of advanced age, there is also the question of which provider is best positioned to counsel patients regarding this decision-making. Does the onus fall on the gastroenterologist (the proceduralist ultimately performing the procedure) or the PCP (who is likely more familiar with the patient’s overall health profile)? In a recent survey, more than 50% of PCPs reported feeling uncertain in their understanding of risk versus benefit stratification of continued CRC screening in older adults.2 While there may be justification for both classes of providers to be involved, in my opinion, the decision to maintain or halt surveillance in older adults should be primarily guided by the gastroenterologist who is better equipped to provide individualized guidance regarding the nuanced risks of disease progression in these patients with prior history of adenomas, and who is clinically responsible for any procedure-related complications.
In an era of cost containment, insurance companies are increasingly placing barriers for approving surveillance and diagnostic colonoscopies. Thus, we need to be ever mindful of appropriately allocating resources to best benefit patients. The data on incidence of polyps and CRC in older adults is inconsistent and even difficult at times for a gastroenterologist to interpret. Therefore, in my opinion, the onus should not fall solely on the PCPs who are not routinely familiar with this information. We as gastroenterologists typically have greater domain-specific knowledge regarding current data and updated guidelines.
Gastroenterologists should wield this expertise to regulate overly liberalized recommendations for continued surveillance in fragile patients, or conversely to intervene in settings of prematurely halting surveillance in high-risk populations with appropriate life expectancy to experience disease progression. It is critical to carefully consider patient-individualized life expectancies, avoid surveillance in patients without clinically significant polyps, avoid over-weighting previous abnormal prior colonoscopies without reviewing more current procedure results, and take time to discuss patient preferences. As proceduralists, we must also be mindful of intrinsic biases towards performing surveillance in patients who are not likely to benefit from this intervention, and several studies have reported on the overuse of surveillance colonoscopies in the form of repeating surveillance earlier than recommended or in the context of limited life expectancy.3
Finally, it is necessary to emphasize that PCPs are critical allies for promoting overall patient health, especially in scenarios where recommendations to discontinue surveillance may not coincide with patient preference. It has been reported that patients usually do not consider poor overall health relevant to decisions regarding CRC surveillance (which I have also experienced to be true).4 In these scenarios, partnering with the PCP can be strategic, as patients may be more inclined to trust the guidance of their more familiar physician. At the end of the day, regardless of which provider takes ownership of initiating the discussion surrounding surveillance colonoscopy in older adults, communication is key between all providers and the patient to ensure optimal outcomes.
As the U.S. population continues to age, the demographic of patients aged 65 and older is projected to nearly double by 2060.5 Decisions regarding ongoing surveillance for CRC will continue to be frequent and increasingly relevant. The importance of studies generating high-quality data to inform appropriate guidelines specific to this population cannot be understated.
Dr. Naveed is a gastroenterologist and director of the gastroenterology and hepatology fellowship program at AdventHealth Medical Group, Altamonte Springs, Fla. Dr. Naveed had no relevant disclosures.
References
1. Patel SG et al. Gastroenterology. 2022 Jan;162(1):285-99.
2 Schoenborn NL et al. Am J Gastroenterol. 2023 Mar 1;118(3):523-30.
3 Calderwood AH et al. JAMA Intern Med. 2023 May 1;183(5):426-34.
4 Schoenborn NL et al. Am J Gastroenterol. 2023 Mar 1;118(3):523-30.
5 U.S. Census Bureau. Population Projections.
Dear colleagues,
Colonoscopy is the bread and butter of endoscopy. Multidisciplinary updates continue to support screening colonoscopy in reducing the risk of developing colorectal cancer. But there has been debate about the best uses of resources, especially with increased recognition of colorectal cancer (CRC) in younger patients, and successive guidelines lengthening the intervals for most surveillance colonoscopy.
In particular, when do we feel comfortable recommending cessation of surveillance colonoscopy especially in those who are 75-85 years old? Routine colonoscopy remains a very low-risk procedure even in older patients with multiple comorbidities.
In this issue of Perspectives, Dr. Petr Protiva and Dr. Mariam Naveed address this issue and provide differing perspectives on approaching surveillance colonoscopy in the elderly.
We welcome your thoughts on this issue on Twitter at @AGA_GIHN.
Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.
Striking a balance: Deciding the optimal age to cease surveillance for colorectal neoplasia
BY PETR PROTIVA, MD, MPH
The appropriate age to stop surveillance for colorectal neoplasia remains uncertain. Screening for average-risk individuals is typically stopped at age 75, but personalized screening with shared decision-making may continue until age 85.1 Evidence suggests that any survival benefit of screening past age 86 would be outweighed by the harm of screening and/or natural mortality. Nevertheless, determining the optimal age for surveillance in those with a history of neoplasia still poses some challenges. The issue is confounded as many clinicians use the terms “screening” and “surveillance” interchangeably. It should be noted that screening implies the individual is at average risk, while surveillance refers to those at elevated risk because of a personal history of colonic adenomas or cancer
Comorbidities and life expectancy
Despite recent staggering setbacks and a drop in the average life expectancy in the United States, the proportion of individuals older than 65 years old has been steadily increasing to a currently estimated 58.9 million – 16.8% of the U.S. population – and is projected to increase in the future.2 However, the prevalence of comorbidities also increases with age, and these are crucial factors to weigh in the decision-making process. Severe comorbid conditions, such as chronic obstructive pulmonary disease, cirrhosis, chronic hepatitis, chronic renal failure, dementia, and congestive heart failure can limit a patient’s ability to undergo surveillance and diminish or negate its benefits. There are online tools that help clinicians estimate life expectancy and time to benefit (that is, time between the intervention and its benefit), such as the Lee or Schonberg index.3 Consensus on time to colorectal screening benefit is about 9-10 years, but may be much shorter for surveillance. Striking a balance between the potential benefits of continued surveillance and the risks and burdens imposed on older adults with limited life expectancy is essential for making well-informed decisions.
Age-related risk increase and risk of neoplasia in the surveillance population:
The absolute risk of developing colorectal cancer is dependent on age. In adults aged 45-49, it is 33.4/100,000, rising to 135.6 in those 70-74 years old; in persons aged 85 and older, it is 234.7/100,000.4 A significant challenge in determining the appropriate age to stop surveillance is the additional individual risk based on baseline polyp characteristics. It seems reasonable to treat low-risk adenomas similarly to screening and stop surveillance by 85 or 86 years old in most cases. The decision process is less clear in individuals with advanced lesions or a personal history of colon cancer. The prevalence of advanced adenomas on the baseline exam is about 15% and greater than 20% on the follow-up exam if the index adenoma(s) were at least 20 mm in diameter. For five or more adenomas at baseline, the prevalence of advanced lesions on follow-up exam is about 20%. On the other hand, a negative surveillance colonoscopy (that is, no polyps found) is associated with far fewer advanced lesions on follow-up.
Colonoscopy
The safety of colonoscopy in older adults should be considered. The colonoscopy procedure is generally very safe, but is associated with a higher risk of post-procedure complications after outpatient colonoscopy in patients 75 years and older. In addition, comorbidities such as anemia, cardiac arrhythmia, heart failure, hypertension, chronic kidney disease, liver disease, smoking history, and obesity are also risk factors. It should be noted that high-quality colonoscopy is key to the detection and full removal of neoplastic lesions and risk reduction. The inability to achieve adequate colon preparation for any reason or undertaking colonoscopy in patients at high risk for complications reduces its benefit.
Who should oversee surveillance, the primary care physician or gastroenterologist
Should a gastroenterologist oversee the decision on surveillance in older adults based on a combination of age, estimated procedure risk and benefits, patient preferences, and current guidelines? Certainly, it seems appropriate and that this is what most specialists think, according to a recent survey of gastroenterologists and primary care physicians (PCPs) on this topic.5 Perhaps, not surprisingly, most PCPs disagreed – PCPs are thoroughly familiar with their patients’ up-to-date comorbidities, functional status, and preferences, and they have the benefit of knowing them for a long time. They also integrate diagnostic results from multiple subspecialists, sometimes from different states. The role of PCPs is critical in centers that offer open-access colonoscopy. Gastroenterologists may be the most appropriate authority to evaluate older individuals for continued surveillance, but in most busy practices these patients are seen by mid-level practitioners. Specialists play an important role if the PCP is uncertain whether surveillance is still indicated or in older patients with a history of advanced adenoma. Therefore, the colonoscopy report or subsequent communication after pathology results are returned should include a recommendation for future surveillance and a clear provision for discontinuing the surveillance in case of future health decline.
Conclusion
Determining the optimal age to discontinue surveillance for colorectal neoplasia involves evaluating multiple factors. Although the age limit is clearer for average-risk screening and low-risk lesion surveillance, uncertainty remains for individuals with advanced neoplasia history. Significant factors in this decision-making process include subsequent neoplasia risk, comorbidities, life expectancy, and age-related risks associated with colonoscopy. Cooperation between PCPs and subspecialty physicians is essential in making surveillance decisions for older adults. PCPs are well positioned to consider detailed patient comorbidities, functional status, and patient preferences, especially with the help of online life-expectancy estimators for most elderly or comorbid patients. To assist in this process, gastroenterologists should state clearly in their procedure report and subsequent pathology letters whether surveillance is recommended and that it is conditional on future comorbidities and should be discontinued if the patient’s health significantly declines.
Dr. Protiva is associate professor of medicine, Yale University, and director of the colon cancer screening program, VA Connecticut Healthcare System, West Haven. Dr. Protiva has no relevant disclosures.
References
1. Patel SG et al. Gastroenterology. 2022;162:285-99
2. U.S. Census Bureau. Measuring America’s People, Places, and Economy
3. University of California, San Francisco. ePrognosis. 4. Siegel RL et al. CA Cancer J Clin. 2023 May-Jun;73(3):233-54.
5. Schoenborn NL et al. Am J Gastroenterol. 2023; 118(3):523-30.
The gastroenterologist should guide the decision to maintain, or halt, surveillance in older adults
BY MARIAM NAVEED, MD
Endoscopic screening and surveillance for CRC in older adults (≥ 75 years old) is a medical “gray area” that needs more high-quality data to inform clinical decision making. In the most recent 2022 clinical guideline update from the U.S. Multisociety Task Force on Colorectal Cancer, the recommendation to stop CRC screening in average risk patients older than 86 years is well supported because of colonoscopy-associated mortality risk outweighing the benefits of adenoma detection and removal. By comparison, screening recommendations for average risk individuals between 76-85 years old are ambiguous and ultimately the decision to proceed with colonoscopy in this clinical population should be individualized based on shared decision making between the provider and patient. Of note, the same guideline provides no specific guidance for ongoing surveillance in the same age group and similarly suggests a shared decision-making approach.1
As a practicing gastroenterologist in the retirement capital of Florida, older adults comprise a large portion of my clinical practice. I have noticed several aspects unique to this demographic that merit special consideration. For example, a significant percentage of these patients are seasonal (that is, “snowbird”) patients that have multiple sets of doctors (set of physicians in their home state and another set in Florida). Consequently, fragmentation of clinical data enables opportunities for colonoscopies to be wrongly ordered (either in an inappropriate time frame and/or for inaccurate indications). In my own practice, when such a patient is referred for consideration of CRC surveillance, any/all external records must first be obtained and validated as a prerequisite for appropriate clinical counseling and informed decision-making. Additionally, consideration of periprocedural risks is particularly relevant in older adults, secondary to both the increased rate of direct complications and the likelihood of pre-existing comorbidities affecting completion of a safe colonoscopy. Factors that can be easily overlooked include higher rates of poor bowel preparation and corresponding decreased completion rates. Moreover, if the patient has a history of high-risk adenomas or worrisome family history warranting ongoing evaluation, but they also have high-risk comorbidities, I will frequently involve the patient’s cardiologist or pulmonologist to provide medical clearance prior to offering CRC screening/surveillance.
In addition to the clinical ambiguity of appropriateness of continued CRC screening/surveillance in the setting of advanced age, there is also the question of which provider is best positioned to counsel patients regarding this decision-making. Does the onus fall on the gastroenterologist (the proceduralist ultimately performing the procedure) or the PCP (who is likely more familiar with the patient’s overall health profile)? In a recent survey, more than 50% of PCPs reported feeling uncertain in their understanding of risk versus benefit stratification of continued CRC screening in older adults.2 While there may be justification for both classes of providers to be involved, in my opinion, the decision to maintain or halt surveillance in older adults should be primarily guided by the gastroenterologist who is better equipped to provide individualized guidance regarding the nuanced risks of disease progression in these patients with prior history of adenomas, and who is clinically responsible for any procedure-related complications.
In an era of cost containment, insurance companies are increasingly placing barriers for approving surveillance and diagnostic colonoscopies. Thus, we need to be ever mindful of appropriately allocating resources to best benefit patients. The data on incidence of polyps and CRC in older adults is inconsistent and even difficult at times for a gastroenterologist to interpret. Therefore, in my opinion, the onus should not fall solely on the PCPs who are not routinely familiar with this information. We as gastroenterologists typically have greater domain-specific knowledge regarding current data and updated guidelines.
Gastroenterologists should wield this expertise to regulate overly liberalized recommendations for continued surveillance in fragile patients, or conversely to intervene in settings of prematurely halting surveillance in high-risk populations with appropriate life expectancy to experience disease progression. It is critical to carefully consider patient-individualized life expectancies, avoid surveillance in patients without clinically significant polyps, avoid over-weighting previous abnormal prior colonoscopies without reviewing more current procedure results, and take time to discuss patient preferences. As proceduralists, we must also be mindful of intrinsic biases towards performing surveillance in patients who are not likely to benefit from this intervention, and several studies have reported on the overuse of surveillance colonoscopies in the form of repeating surveillance earlier than recommended or in the context of limited life expectancy.3
Finally, it is necessary to emphasize that PCPs are critical allies for promoting overall patient health, especially in scenarios where recommendations to discontinue surveillance may not coincide with patient preference. It has been reported that patients usually do not consider poor overall health relevant to decisions regarding CRC surveillance (which I have also experienced to be true).4 In these scenarios, partnering with the PCP can be strategic, as patients may be more inclined to trust the guidance of their more familiar physician. At the end of the day, regardless of which provider takes ownership of initiating the discussion surrounding surveillance colonoscopy in older adults, communication is key between all providers and the patient to ensure optimal outcomes.
As the U.S. population continues to age, the demographic of patients aged 65 and older is projected to nearly double by 2060.5 Decisions regarding ongoing surveillance for CRC will continue to be frequent and increasingly relevant. The importance of studies generating high-quality data to inform appropriate guidelines specific to this population cannot be understated.
Dr. Naveed is a gastroenterologist and director of the gastroenterology and hepatology fellowship program at AdventHealth Medical Group, Altamonte Springs, Fla. Dr. Naveed had no relevant disclosures.
References
1. Patel SG et al. Gastroenterology. 2022 Jan;162(1):285-99.
2 Schoenborn NL et al. Am J Gastroenterol. 2023 Mar 1;118(3):523-30.
3 Calderwood AH et al. JAMA Intern Med. 2023 May 1;183(5):426-34.
4 Schoenborn NL et al. Am J Gastroenterol. 2023 Mar 1;118(3):523-30.
5 U.S. Census Bureau. Population Projections.
Dear colleagues,
Colonoscopy is the bread and butter of endoscopy. Multidisciplinary updates continue to support screening colonoscopy in reducing the risk of developing colorectal cancer. But there has been debate about the best uses of resources, especially with increased recognition of colorectal cancer (CRC) in younger patients, and successive guidelines lengthening the intervals for most surveillance colonoscopy.
In particular, when do we feel comfortable recommending cessation of surveillance colonoscopy especially in those who are 75-85 years old? Routine colonoscopy remains a very low-risk procedure even in older patients with multiple comorbidities.
In this issue of Perspectives, Dr. Petr Protiva and Dr. Mariam Naveed address this issue and provide differing perspectives on approaching surveillance colonoscopy in the elderly.
We welcome your thoughts on this issue on Twitter at @AGA_GIHN.
Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.
Striking a balance: Deciding the optimal age to cease surveillance for colorectal neoplasia
BY PETR PROTIVA, MD, MPH
The appropriate age to stop surveillance for colorectal neoplasia remains uncertain. Screening for average-risk individuals is typically stopped at age 75, but personalized screening with shared decision-making may continue until age 85.1 Evidence suggests that any survival benefit of screening past age 86 would be outweighed by the harm of screening and/or natural mortality. Nevertheless, determining the optimal age for surveillance in those with a history of neoplasia still poses some challenges. The issue is confounded as many clinicians use the terms “screening” and “surveillance” interchangeably. It should be noted that screening implies the individual is at average risk, while surveillance refers to those at elevated risk because of a personal history of colonic adenomas or cancer
Comorbidities and life expectancy
Despite recent staggering setbacks and a drop in the average life expectancy in the United States, the proportion of individuals older than 65 years old has been steadily increasing to a currently estimated 58.9 million – 16.8% of the U.S. population – and is projected to increase in the future.2 However, the prevalence of comorbidities also increases with age, and these are crucial factors to weigh in the decision-making process. Severe comorbid conditions, such as chronic obstructive pulmonary disease, cirrhosis, chronic hepatitis, chronic renal failure, dementia, and congestive heart failure can limit a patient’s ability to undergo surveillance and diminish or negate its benefits. There are online tools that help clinicians estimate life expectancy and time to benefit (that is, time between the intervention and its benefit), such as the Lee or Schonberg index.3 Consensus on time to colorectal screening benefit is about 9-10 years, but may be much shorter for surveillance. Striking a balance between the potential benefits of continued surveillance and the risks and burdens imposed on older adults with limited life expectancy is essential for making well-informed decisions.
Age-related risk increase and risk of neoplasia in the surveillance population:
The absolute risk of developing colorectal cancer is dependent on age. In adults aged 45-49, it is 33.4/100,000, rising to 135.6 in those 70-74 years old; in persons aged 85 and older, it is 234.7/100,000.4 A significant challenge in determining the appropriate age to stop surveillance is the additional individual risk based on baseline polyp characteristics. It seems reasonable to treat low-risk adenomas similarly to screening and stop surveillance by 85 or 86 years old in most cases. The decision process is less clear in individuals with advanced lesions or a personal history of colon cancer. The prevalence of advanced adenomas on the baseline exam is about 15% and greater than 20% on the follow-up exam if the index adenoma(s) were at least 20 mm in diameter. For five or more adenomas at baseline, the prevalence of advanced lesions on follow-up exam is about 20%. On the other hand, a negative surveillance colonoscopy (that is, no polyps found) is associated with far fewer advanced lesions on follow-up.
Colonoscopy
The safety of colonoscopy in older adults should be considered. The colonoscopy procedure is generally very safe, but is associated with a higher risk of post-procedure complications after outpatient colonoscopy in patients 75 years and older. In addition, comorbidities such as anemia, cardiac arrhythmia, heart failure, hypertension, chronic kidney disease, liver disease, smoking history, and obesity are also risk factors. It should be noted that high-quality colonoscopy is key to the detection and full removal of neoplastic lesions and risk reduction. The inability to achieve adequate colon preparation for any reason or undertaking colonoscopy in patients at high risk for complications reduces its benefit.
Who should oversee surveillance, the primary care physician or gastroenterologist
Should a gastroenterologist oversee the decision on surveillance in older adults based on a combination of age, estimated procedure risk and benefits, patient preferences, and current guidelines? Certainly, it seems appropriate and that this is what most specialists think, according to a recent survey of gastroenterologists and primary care physicians (PCPs) on this topic.5 Perhaps, not surprisingly, most PCPs disagreed – PCPs are thoroughly familiar with their patients’ up-to-date comorbidities, functional status, and preferences, and they have the benefit of knowing them for a long time. They also integrate diagnostic results from multiple subspecialists, sometimes from different states. The role of PCPs is critical in centers that offer open-access colonoscopy. Gastroenterologists may be the most appropriate authority to evaluate older individuals for continued surveillance, but in most busy practices these patients are seen by mid-level practitioners. Specialists play an important role if the PCP is uncertain whether surveillance is still indicated or in older patients with a history of advanced adenoma. Therefore, the colonoscopy report or subsequent communication after pathology results are returned should include a recommendation for future surveillance and a clear provision for discontinuing the surveillance in case of future health decline.
Conclusion
Determining the optimal age to discontinue surveillance for colorectal neoplasia involves evaluating multiple factors. Although the age limit is clearer for average-risk screening and low-risk lesion surveillance, uncertainty remains for individuals with advanced neoplasia history. Significant factors in this decision-making process include subsequent neoplasia risk, comorbidities, life expectancy, and age-related risks associated with colonoscopy. Cooperation between PCPs and subspecialty physicians is essential in making surveillance decisions for older adults. PCPs are well positioned to consider detailed patient comorbidities, functional status, and patient preferences, especially with the help of online life-expectancy estimators for most elderly or comorbid patients. To assist in this process, gastroenterologists should state clearly in their procedure report and subsequent pathology letters whether surveillance is recommended and that it is conditional on future comorbidities and should be discontinued if the patient’s health significantly declines.
Dr. Protiva is associate professor of medicine, Yale University, and director of the colon cancer screening program, VA Connecticut Healthcare System, West Haven. Dr. Protiva has no relevant disclosures.
References
1. Patel SG et al. Gastroenterology. 2022;162:285-99
2. U.S. Census Bureau. Measuring America’s People, Places, and Economy
3. University of California, San Francisco. ePrognosis. 4. Siegel RL et al. CA Cancer J Clin. 2023 May-Jun;73(3):233-54.
5. Schoenborn NL et al. Am J Gastroenterol. 2023; 118(3):523-30.
The gastroenterologist should guide the decision to maintain, or halt, surveillance in older adults
BY MARIAM NAVEED, MD
Endoscopic screening and surveillance for CRC in older adults (≥ 75 years old) is a medical “gray area” that needs more high-quality data to inform clinical decision making. In the most recent 2022 clinical guideline update from the U.S. Multisociety Task Force on Colorectal Cancer, the recommendation to stop CRC screening in average risk patients older than 86 years is well supported because of colonoscopy-associated mortality risk outweighing the benefits of adenoma detection and removal. By comparison, screening recommendations for average risk individuals between 76-85 years old are ambiguous and ultimately the decision to proceed with colonoscopy in this clinical population should be individualized based on shared decision making between the provider and patient. Of note, the same guideline provides no specific guidance for ongoing surveillance in the same age group and similarly suggests a shared decision-making approach.1
As a practicing gastroenterologist in the retirement capital of Florida, older adults comprise a large portion of my clinical practice. I have noticed several aspects unique to this demographic that merit special consideration. For example, a significant percentage of these patients are seasonal (that is, “snowbird”) patients that have multiple sets of doctors (set of physicians in their home state and another set in Florida). Consequently, fragmentation of clinical data enables opportunities for colonoscopies to be wrongly ordered (either in an inappropriate time frame and/or for inaccurate indications). In my own practice, when such a patient is referred for consideration of CRC surveillance, any/all external records must first be obtained and validated as a prerequisite for appropriate clinical counseling and informed decision-making. Additionally, consideration of periprocedural risks is particularly relevant in older adults, secondary to both the increased rate of direct complications and the likelihood of pre-existing comorbidities affecting completion of a safe colonoscopy. Factors that can be easily overlooked include higher rates of poor bowel preparation and corresponding decreased completion rates. Moreover, if the patient has a history of high-risk adenomas or worrisome family history warranting ongoing evaluation, but they also have high-risk comorbidities, I will frequently involve the patient’s cardiologist or pulmonologist to provide medical clearance prior to offering CRC screening/surveillance.
In addition to the clinical ambiguity of appropriateness of continued CRC screening/surveillance in the setting of advanced age, there is also the question of which provider is best positioned to counsel patients regarding this decision-making. Does the onus fall on the gastroenterologist (the proceduralist ultimately performing the procedure) or the PCP (who is likely more familiar with the patient’s overall health profile)? In a recent survey, more than 50% of PCPs reported feeling uncertain in their understanding of risk versus benefit stratification of continued CRC screening in older adults.2 While there may be justification for both classes of providers to be involved, in my opinion, the decision to maintain or halt surveillance in older adults should be primarily guided by the gastroenterologist who is better equipped to provide individualized guidance regarding the nuanced risks of disease progression in these patients with prior history of adenomas, and who is clinically responsible for any procedure-related complications.
In an era of cost containment, insurance companies are increasingly placing barriers for approving surveillance and diagnostic colonoscopies. Thus, we need to be ever mindful of appropriately allocating resources to best benefit patients. The data on incidence of polyps and CRC in older adults is inconsistent and even difficult at times for a gastroenterologist to interpret. Therefore, in my opinion, the onus should not fall solely on the PCPs who are not routinely familiar with this information. We as gastroenterologists typically have greater domain-specific knowledge regarding current data and updated guidelines.
Gastroenterologists should wield this expertise to regulate overly liberalized recommendations for continued surveillance in fragile patients, or conversely to intervene in settings of prematurely halting surveillance in high-risk populations with appropriate life expectancy to experience disease progression. It is critical to carefully consider patient-individualized life expectancies, avoid surveillance in patients without clinically significant polyps, avoid over-weighting previous abnormal prior colonoscopies without reviewing more current procedure results, and take time to discuss patient preferences. As proceduralists, we must also be mindful of intrinsic biases towards performing surveillance in patients who are not likely to benefit from this intervention, and several studies have reported on the overuse of surveillance colonoscopies in the form of repeating surveillance earlier than recommended or in the context of limited life expectancy.3
Finally, it is necessary to emphasize that PCPs are critical allies for promoting overall patient health, especially in scenarios where recommendations to discontinue surveillance may not coincide with patient preference. It has been reported that patients usually do not consider poor overall health relevant to decisions regarding CRC surveillance (which I have also experienced to be true).4 In these scenarios, partnering with the PCP can be strategic, as patients may be more inclined to trust the guidance of their more familiar physician. At the end of the day, regardless of which provider takes ownership of initiating the discussion surrounding surveillance colonoscopy in older adults, communication is key between all providers and the patient to ensure optimal outcomes.
As the U.S. population continues to age, the demographic of patients aged 65 and older is projected to nearly double by 2060.5 Decisions regarding ongoing surveillance for CRC will continue to be frequent and increasingly relevant. The importance of studies generating high-quality data to inform appropriate guidelines specific to this population cannot be understated.
Dr. Naveed is a gastroenterologist and director of the gastroenterology and hepatology fellowship program at AdventHealth Medical Group, Altamonte Springs, Fla. Dr. Naveed had no relevant disclosures.
References
1. Patel SG et al. Gastroenterology. 2022 Jan;162(1):285-99.
2 Schoenborn NL et al. Am J Gastroenterol. 2023 Mar 1;118(3):523-30.
3 Calderwood AH et al. JAMA Intern Med. 2023 May 1;183(5):426-34.
4 Schoenborn NL et al. Am J Gastroenterol. 2023 Mar 1;118(3):523-30.
5 U.S. Census Bureau. Population Projections.
