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Impact of Age and Comorbidity on Colorectal Cancer Screening Among Older Veterans
- Louise C. Walter, MD;
- Karla Lindquist, MS;
- Sean Nugent, BA;
- Tammy Schult, MS;
- Sei J. Lee, MD, MAS;
- Michele A. Casadei, BS; and
- Melissa R. Partin, PhD
- From the San Francisco Veterans Affairs Medical Center and the University of California, San Francisco, California, and the Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota.
Abstract
Background: The Veterans Health Administration, the American Cancer Society, and the American Geriatrics Society recommend colorectal cancer screening for older adults unless they are unlikely to live 5 years or have significant comorbidity that would preclude treatment.
Objective: To determine whether colorectal cancer screening is targeted to healthy older patients and is avoided in older patients with severe comorbidity who have life expectancies of 5 years or less.
Design: Cohort study.
Setting: Veterans Affairs (VA) medical centers in Minneapolis, Minnesota; Durham, North Carolina; Portland, Oregon; and West Los Angeles, California, with linked national VA and Medicare administrative claims.
Patients: 27 068 patients 70 years or older who had an outpatient visit at 1 of 4 VA medical centers in 2001 or 2002 and were due for screening.
Measurements: The main outcome was receipt of fecal occult blood testing (FOBT), colonoscopy, sigmoidoscopy, or barium enema in 2001 or 2002, on the basis of national VA and Medicare claims. Charlson–Deyo comorbidity scores at the start of 2001 were used to stratify patients into 3 groups ranging from no comorbidity (score of 0) to severe comorbidity (score ≥4), and 5-year mortality was determined for each group.
Results: 46% of patients were screened from 2001 through 2002. Only 47% of patients with no comorbidity were screened despite having life expectancies greater than 5 years (5-year mortality, 19%). Although the incidence of screening decreased with age and worsening comorbidity, it was still 41% for patients with severe comorbidity who had life expectancies less than 5 years (5-year mortality, 55%). The number of VA outpatient visits predicted screening independent of comorbidity, such that patients with severe comorbidity and 4 or more visits had screening rates similar to or higher than those of healthier patients with fewer visits.
Limitations: Some tests may have been performed for nonscreening reasons. The generalizability of findings to persons who do not use the VA system is uncertain.
Conclusion: Advancing age was inversely associated with colorectal cancer screening, whereas comorbidity was a weaker predictor. More attention to comorbidity is needed to better target screening to older patients with substantial life expectancies and avoid screening older patients with limited life expectancies.
Primary Funding Source: VA Health Services Research and Development.
Article and Author Information
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Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.
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Grant Support: Dr. Walter is supported by VA Health Services Research and Development grant IIR-04-427 and is a Robert Wood Johnson Physician Faculty Scholar. Dr. Lee is a Hartford Geriatrics Health Outcomes Research Scholar.
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Potential Financial Conflicts of Interest: None disclosed.
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Reproducible Research Statement: Study protocol and statistical code: Available from Dr. Walter (louise.walter{at}ucsf.edu). Data set: Not available.
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Requests for Single Reprints: Louise C. Walter, MD, Veterans Affairs Medical Center 181G, 4150 Clement Street, San Francisco, CA 94121; e-mail, louise.walter{at}ucsf.edu.
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Current Author Addresses: Drs. Walter and Lee, Ms. Lindquist, and Ms. Casadei: Veterans Affairs Medical Center 181G, 4150 Clement Street, San Francisco, CA 94121.
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Mr. Nugent, Ms. Schult, and Dr. Partin: Minneapolis Veterans Affairs Medical Center, 1 Veterans Drive (152/2E), Minneapolis MN 55417.
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Author Contributions: Conception and design: L.C. Walter.
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Analysis and interpretation of the data: L.C. Walter, K. Lindquist, S. Nugent, S.J. Lee, M.R. Partin.
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Drafting of the article: L.C. Walter, M.R. Partin.
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Critical revision of the article for important intellectual content: L.C. Walter, K. Lindquist, S.J. Lee, M.R. Partin.
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Final approval of the article: L.C. Walter, S.J. Lee, M.R. Partin.
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Provision of study materials or patients: M.R. Partin.
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Statistical expertise: K. Lindquist.
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Obtaining of funding: L.C. Walter.
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Administrative, technical, or logistic support: M.A. Casadei.
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Collection and assembly of data: L.C. Walter, S. Nugent, T. Schult, M.R. Partin.
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