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Misinterpretations of Updated Colorectal Cancer Screening Guidelines Observed in the Community
Submit responseWe read with great interest the recent update of the 2002 U.S. Preventive Services Task Force (USPSTF) recommendation statement for colorectal cancer screening. One significant update is the recommendation against routine screening for colorectal cancer in adults ages 76-85 (1). We are concerned about the potential for confusion regarding the term “routine screening." In our clinic, we have already encountered several elderly patients who were inappropriately informed by their primary care physicians that, based on the “new guidelines”, they did not need any further colorectal cancer screening simply because they were older than 75 years of age. Routine screening only refers to patients who have previously undergone appropriate colorectal cancer screening that did not reveal colonic adenomas or cancer. Routine screening does not refer to “surveillance” exams, nor does it refer to the screening of individuals 76 -85 years of age who have not had a prior colonoscopy. Although these differences are clearly defined within the body of the paper, misinterpretations are occurring.
Since a majority of patients base health care decisions on their physician’s opinion, it is important for physicians to understand the new guidelines. In one study, 85% of those surveyed preferred physician input into the decision, with 16% preferring that the physician solely decide (2). In patients age 76-85 with a history of colorectal adenomas/cancer or those who have not been previously screened, the clinician should be prepared to give input which is both informative and evidentiary.
One potential pitfall in the decision to screen elderly patients is for clinicians to use signs or symptoms related to advanced lesions (anemia, bleeding, abdominal pain, or change in bowel habits) as a breakpoint for screening. In unpublished data, we examined the endoscopic findings of 107 consecutive asymptomatic patients age 75-85 who underwent a first-ever screening colonoscopy. Adenomas were detected in 50 patients (46.8%) while colorectal cancer was detected in 4 patients (3.7%). Interestingly, colorectal cancer was detected in 13% of patients age 81-85. Although this is a small study, it does provide support for first-time colorectal cancer screening in individuals age 76-85. However, the ultimate decision to proceed with colonoscopy should be based on the individual patient’s health and wishes once appropriate informed consent has been provided.
References:
1. U.S. Preventative Services Task Force. Screening for colorectal cancer: U.S. Preventative Services Task Force Statement. Ann Intern Med 2008;149:627-637.
2. Messina CR, Lane DS, Grimson R. Colorectal cancer screening attitudes and practices: Preferences for decision making. American Journal of Preventive Medicine 2005; 28(5):439-446.
Conflict of Interest:
None declared
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Age is a blunt instrument for selecting patients for screening
Submit responseTo the editor:
We applaud the efforts of the U.S. Preventive Services Task Force to guide patient selection for colorectal cancer screening. Because screening has been shown to reduce colorectal cancer mortality starting approximately 7 years after screening (1), patients with a short life expectancy are unlikely to benefit.
The guideline recommends against routine screening in those 76 years and over. However, we are concerned that age alone is too blunt of an exclusion criterion. Many individuals in their 50s, 60s, or early 70s are unlikely to live the 7 years necessary for benefit, whereas many healthy individuals more than 75 years of age are likely to live far beyond 7 years, and might benefit from screening.
Indeed, Gross and colleagues (2) have shown that the presence of chronic medical conditions is a strong predictor of life expectancy after a diagnosis of stage I colon cancer. Persons in their early 70s with 3 or more chronic conditions had a life expectancy of only about 5 or 6 years when diagnosed with stage I colon cancer. This suggests relatively little gain in life expectancy from the early diagnosis of cancer. Conversely, a decision analysis by Ko and Sonnenberg (3) found that 75-84 year olds in the highest quartile of life expectancy would receive similar benefits from initiation of colorectal cancer screening as would 50-54 year olds with median life expectancy.
Older adults are a heterogeneous group, in which age can belie surprisingly short or long life expectancies. We encourage basing screening decisions on validated prognostic models (4) that consider predictive factors besides age (e.g., comorbidity, frailty). Increasing sophistication of decision support is making it more feasible to incorporate these models into clinical care. Looking beyond age holds promise to better target patients who are likely to benefit from colorectal cancer screening and to avoid harming patients who are unlikely to benefit from screening.
1. U.S. Preventive Services Task Force. Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;149:627-637.
2. Gross CP et al. The effect of age and chronic illness on life expectancy after a diagnosis of colorectal cancer: implications for screening. Ann Intern Med 2006;145:646-653.
3. Ko CW, Sonnenberg A. Comparing risks and benefits of colorectal cancer screening in elderly patients. Gastroenterology 2005;129:1163-1170.
4. Lee SJ, Lindquist K, Segal MR, Covinsky KE. Development and validation of a prognostic index for 4-year mortality in older adults. JAMA 2006;295:801-808.
Conflict of Interest:
None declared