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Takeaway: An editorial in JAMA cited a study led by HSR investigators as providing “long-awaited insights” into the wisdom of recommending colorectal cancer (CRC) screening for older individuals, with or without adenoma history. “The assumption that individuals older than 75 years without adenoma and, even those with adenoma (common type of polyp), are more likely to succumb to other competing causes of mortality can stand on firmer ground with evidence to support the otherwise empirical decision by the US Preventive Services Task Force and the American Cancer Society to recommend against routine colonoscopy screening after individuals reach 75 years of age.”
The risk of developing cancer increases with age, and it is the second leading cause of death among older adults. Simultaneously, older adults face increasing risks for non-cancer mortality, particularly with higher levels of frailty. Therefore, adults aged 75 years and older, and their clinicians, are increasingly faced with difficult decisions regarding whether to continue cancer screening and surveillance. For older adults, the benefits of continued surveillance are uncertain, and current guidelines do not provide clear age or frailty-based recommendations for the de-implementation of surveillance.
A colorectal adenoma is a common type of polyp that can form on the inner lining of the colon or rectum. There are different types of adenomas (i.e., tubular, villous), which are not cancerous; however, they are more likely to become cancerous than other types of polyps if they are not removed. (NIH)
Co-led by HSR researchers Samir Gupta, MD, MSCS, and Folasade May, MD, PhD, VA investigators and colleagues conducted a retrospective cohort study of nearly 92,000 Veterans 75 years of age or older who had undergone a colonoscopy between January 1, 2006, and December 31, 2019. The colonoscopy performed closest in time prior to turning 75 was used for ascertaining adenoma status. The goal of this study was to estimate colorectal cancer (CRC) risks, non-CRC mortality, and all-cause mortality among Veterans with versus without adenoma at prior colonoscopy.
For individuals without adenoma, current guidelines recommend against repeating colonoscopy screening for adults older than 75 years, noting that people exposed to prior screening, such as colonoscopy, with normal findings are likely to benefit minimally.
This study found that among Veterans in a large cohort who remained free from cancer to the age of 75, those with adenoma found on a prior colonoscopy had a higher risk for subsequent CRC and CRC death versus Veterans without adenoma on a prior colonoscopy. However, the absolute cumulative rates of CRC and CRC death were low for both groups of individuals, suggesting older adults can consider deprioritizing surveillance colonoscopy relative to other health concerns.1
An editorial in JAMA cited this study as providing “long-awaited insights” into the wisdom of recommending CRC screening for older individuals, with or without adenoma. “The assumption that individuals older than 75 years without adenoma and, even those with adenoma, are more likely to succumb to other competing causes of mortality can stand on firmer ground with evidence to support the otherwise empirical decision by the US Preventive Services Task Force and the American Cancer Society to recommend against routine colonoscopy screening after individuals reach 75 years of age.”2
Samir Gupta, MD, MS, is a gastroenterologist and part of the VA San Diego Healthcare System. Folasade May, MD, PhD, is a gastroenterologist and investigator with HSR’s Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP); she is also Associate Director of the UCLA Kaiser Permanente Center for Health Equity.
