Colorectal Cancer Screening and Surveillance and Other Colon Conditions in the Older Adult

The incidence of colorectal cancer (CRC) increases with age and the decision to continue or stop screening and surveillance can be complex and should factor in the patient's risk of CRC, prior screening history, comorbidities and competing health priorities, and preferences. Other diseases of the colon including diverticular disease and its complications, ischemic and microscopic colitis also increase in incidence with age and require careful diagnostic and therapeutic approaches. In the sections below, we discuss these conditions in detail, outlining a practical and evidence-based approach specific for older individuals. COLORECTAL CANCER PREVENTION CRC is the third most common cancer in both men and women in the US, and the second leading cause of cancer-related death (1). The median age for diagnosis of sporadic CRC is 66 (2). Individuals ≥70 years account for >60% of cases (3). Current CRC screening guidelines for older individuals Current CRC guidelines by the US preventive services task force, American College of Gastroenterology and the US Multi-Society Task Force recommend screening average-risk men and women between age 45 and 75 years. Between age 76 to 85, screening decisions should be individualized, based on the person's prior screening history, comorbidities, and preferences. For patients ≥85 years, most guidelines recommend against CRC screening as risks outweigh benefits (Figure 1) (4–6). CRC is slow growing and the sequence of progression from adenoma to carcinoma is estimated to take 8 years–20 years, a time interval that exceeds expected life expectancy for the majority of 86-year-olds. Furthermore, studies evaluating benefits and harms of screening colonoscopy in older adults have reported low benefit and potential for harm (7,8). One large prospective study of Medicare beneficiaries reported no reduction in risk of CRC over 8 years in individuals aged 70–74 years or those aged 75–79 years, with or without screening colonoscopy (7). The excess 30-day risk for any adverse event in the colonoscopy group was 5.6 events per 1,000 individuals in the 70- to 74-year age group and 10.3 per 1,000 in the 75- to 79-year age group.Figure 1.: Summary of age-related CRC screening guidelines and modalities by the major societies in the US. ACG, American College of Gastroenterology; CC, colon capsule; CTC, computed tomography colonography; FIT, fecal immunochemical test; gFOBT, guaiac fecal occult blood test; MSTF, Multi-Society Task Force; mts-DNA, multitarget stool DNA test; USPSTF, United States Preventive Services Task Force.Shared decision making Current CRC screening guideline recommendations for age and modalities for CRC screening are summarized in Figure 1. Discussions about CRC screening for older patients are complex, highlighting the role of shared decision making that addresses several important factors (Figure 2): Prior CRC screening history: Patients with no prior CRC screening have a higher likelihood of harboring advanced neoplasia or CRC, given age related increase in prevalence of colorectal lesions. On the other hand, patients up to date on CRC screening, with negative prior CRC screening (such as a negative colonoscopy in the past 10 years, negative stool tests in the last 5 years) are at a much lower risk of harboring future neoplasia, as they are already risk stratified as being at low risk given prior negative screening. The incremental benefit of additional CRC screening is smaller compared to an older individual without prior screening. Comorbidities and life expectancy: Chronological age is often used as a surrogate for life expectancy. Given the slow growing nature of CRC, although older individuals may harbor advanced polyps or neoplasia, it is unlikely that they will develop symptoms or die from it. At older ages, focusing on other health priorities that would modulate their long-term outcome, such as heart disease or functional mobility, provides much greater value. The gains derived from screening in older adults were estimated at ≤15% (9). Given that the life expectancy for most individuals after age 75 is less than 10 years, tailoring screening decision based on comorbidities and life expectancy becomes extremely important. However, the assessment of life expectancy is hampered by lack of reliable and clinically useful calculators. A systematic review of many life expectancy calculators found that none have been validated across populations (10). ePrognosis (available at https://eprognosis.ucsf.edu/) is another tool that takes into account a patient's comorbidities and cognition and can be considered when discussing risks and benefits (11). Surprisingly, higher comorbidity burden is associated with over-screening due to increased contact with the healthcare system (12). Multiple studies have reported that screening frequency remains high in older adults despite high comorbidity burden and low life expectancy (13,14). Harms of CRC screening: The potential harms of CRC screening are related to risks of colonoscopy, used as a primary screening modality or as follow up of a non-invasive CRC screening test. Even though colonoscopy is a generally safe procedure, patients and providers generally underestimate these risks. Ko et al found that the risk of screening related complications in patients between 70 and 94 years was up to 4 fold higher (based on comorbidities) than the estimated benefit in this same age group (15).The risks of colonoscopy are largely related to bowel preparation, alteration in anticoagulation or antiplatelet medications pre-procedure, the procedure itself and sedation. Harms of the procedure itself include perforation, bleeding and peri-procedural cardiac and pulmonary complications. In older patients, procedural sedation can also lead to increased risk of hypoxia, aspiration, hypotension, and arrhythmias. Older patients may benefit from less procedural sedation, and this should be discussed on an individual basis (9). A systematic review for average-risk screening colonoscopies found that the pooled event rate for serious adverse events was 2.8 per 1,000, with bleeding at 8 per 10,000 and perforation 4 per 10,000 colonoscopies (15). These rates have been found to increase with increasing age (16). In patients ≥80 years, the reported risk of all-cause complications rises to 34.8 per 1,000 colonoscopies (17). In order to reduce the risk of harms associated with colonoscopy in older individuals, clinicians may consider using water immersion or exchange, to ease the passage of the colonoscope through the sigmoid and reduce the need for sedation, use of smaller caliber colonoscopes (e.g. pediatric or even upper endoscope) in thin, female older individuals, and use of lower doses of moderate sedation or other combination of anesthetic agents in discussion with the anesthesia team. Finally, overdiagnosis, the diagnosis and treatment of a cancer that would not have otherwise caused symptoms during the individual's remaining lifetime, is a potential harm. Although there is limited data on overdiagnosis in CRC screening, a review of autopsy data showed that 2%–3% of individuals had undiagnosed and unrelated CRC at the time of death (18).Patient Tolerance: Patient tolerance for treatment following a positive screen and ability to undergo therapy if CRC were to be diagnosed should be predetermined to help guide care. Patients who would not tolerate or choose further invasive work-up or treatment for CRC should not undergo screening. In a study of 1,388 endoscopies of the lower gastrointestinal tract among patients ≥80 years, CRC was diagnosed in 6% though over 10% refused curative surgical treatment (19).Patients may also have strong preferences against screening cessation. A survey of veterans aged ≥50 years found that 29% of respondents were not comfortable with cessation of CRC screening despite serious health problems or their physician's recommendation that additional colonoscopies would not be of benefit. Furthermore, 49% of respondents thought age alone should not be used to decide screening cessation (20). Figure 2.: Conceptual diagram showing several factors involved in colorectal cancer prevention decision-making in older adults for 2 cases with relative weighting of these factors. Case A is a healthy 80-year-old person with no co-morbidities, active lifestyle; advanced adenoma 3 years ago; brother with colorectal cancer at age 67. Case B is a 71-year-old with chronic kidney disease, coronary artery disease, and heart failure; screening colonoscopy 5 years ago with one 3 mm adenoma complicated by difficulty prepping (nausea, vomiting) and recovery (delayed return to activities); patient wants to focus on prioritizing function and quality of life, not worried about colorectal cancer. CRC, colorectal cancer.Towards risk stratification models for CRC screening in older individuals There are efforts to develop models on when to stop screening by age integrating the above factors. Hees et al (21) used the Microsimulation Screening Analysis (MISCAN) model incorporating patient age, cancer risk, comorbidities and screening history for age to stop screening. For patients with no prior screening colonoscopy, no comorbidities and a background CRC risk of 0.5 per 1,000, screening up to age 82 was cost effective. However, for a patient with severe comorbidity, prior negative screening and background risk of CRC of 0.5 per 1,000, stopping screening at age 66 should be considered. Cenin et al (22) used the same MISCAN model and factored adherence to biennial screening, age, comorbidities and patient sex. The study demonstrated a stopping age of 82 in females and 80 in male if comorbidities were low and screening adherence was 25%. This study also suggested a stopping age of 66 years in males and females with severe comorbidities and a prior colonoscopy in the past 10 years. Further studies on development and validation of risk stratification models are underway. When to stop surveillance Post-polypectomy surveillance is the most common indication for colonoscopy in older adults, accounting for nearly 6 million procedures per year (23,24). High quality colonoscopy is important to help accurately risk stratify patients based on colonoscopy findings. Current practice in the US promotes ongoing surveillance colonoscopy, making stopping surveillance challenging. Unlike for screening (5), there is no explicit guidance on when to stop surveillance in older adults with a history of polyps, other than that the “decision to continue surveillance should be individualized, based on an assessment of benefit, risk, and comorbidities” (25,26). In addition, the cycle of ongoing, repeated surveillance in older adults is promoted by several factors including recommendations for future colonoscopy made 5–10 years in advance on colonoscopy reports, primary care clinicians who default to these recommendations even as patients age or health status changes, and system-based automatic recall of patients for surveillance. 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