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
Dr. Mariam Naveed
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.
