Tuesday, 21 May, 2024
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How old is too old for colonoscopy?

A large observational study in the US has suggested the risks of surveillance colonoscopy might outweigh the benefits for some older patients, in whom colorectal cancer was rarely detected through this method, regardless of prior adenoma finding.

Medpage Today reports that among 9 601 patients aged 70 to 85 with a history of adenoma, 0.3% of surveillance colonoscopies found colorectal cancer, while 11.7% found advanced adenoma, and 12% found advanced neoplasia.

The results did not differ significantly by age, said the researchers, led by Jeffrey Lee, MD, MPH, of Kaiser Permanente Northern California.

Patients with a history of advanced adenoma versus non-advanced were more likely to have colorectal cancer detected by surveillance, though still rarely (0.5% vs 0.2%, P=0.02), and were more likely to have advanced neoplasia (16.5% vs 10.6%, P<0.001), the group reported in JAMA Network Open.

The findings can help inform whether to continue surveillance colonoscopy in older adults, they said.

“Given the increasing ageing population in the US and that nearly 5.6m adults over 75 years will undergo surveillance annually by 2024, estimating the yield of surveillance colonoscopy is important for understanding the balance between potential benefits and known risks of colonoscopy with advancing age,” they wrote.

In America, 40% of screening colonoscopies find adenomas, and guidelines recommend patients have surveillance colonoscopy after undergoing polypectomy.

However, no age is specified at which surveillance is unlikely to be of substantial benefit and could be stopped, the researchers noted.

Risks associated with colonoscopy increase particularly among patients 75 or older, and include heart attack, stroke, sedation-related adverse events like aspiration pneumonia, bleeding, infection and perforation, the group observed.

“These findings provide some of the first large-scale, community-based information on the yield of surveillance colonoscopy among older adults,” they wrote.

They highlighted two key findings that could inform shared decision making about surveillance colonoscopy.

First, colorectal cancer was rarely detected among older adults with prior advanced or non-advanced adenomas. “Thus, for many older adults, particularly those with a prior non-advanced adenoma, the low rate of (colorectal cancer) detection at surveillance may not justify the potential harms and burdens of colonoscopy that may increase with age,” they said.

They did note that for older adults with a predicted life expectancy of 10 or more years and without significant competing comorbidities, detecting early-stage colorectal cancer or advanced adenomas at surveillance could lead to earlier treatment and improved outcomes, especially for those with a prior advanced adenoma.

Second, advanced adenoma was more commonly detected than colorectal cancer, however, advanced adenomas themselves are not harmful to patients: for the rare lesions that do progress to invasive cancer, the process takes several years.

“Thus, among older adults with limited life expectancies due to comorbidities, few would probably benefit from the detection and removal of these polyps,” they said.

“With current guidelines offering no specific age at which to stop surveillance colonoscopy, the study findings can inform clinicians and older patients regarding the potential benefits (or lack of benefits) of continuing with post polypectomy surveillance in the context of the life expectancy of the patient and weighed against the rare but known harms of colonoscopy, which increase with advancing age and comorbidities.”

Concurring with them, John Carethers, MD, of the University of California San Diego and past president of the American Gastroenterological Association, said the study does not specifically answer the question on the age to stop post-polypectomy surveillance, “but does inform that … a septa- or octogenarian who has previously had advanced neoplasia is more likely to develop it again, but rarely as cancer”.

The population-based, cross-sectional study included patients 70 to 85 with a history of adenoma. Participants underwent a surveillance colonoscopy from 2017-2019 at Kaiser Permanente Northern California, a large, community-based healthcare system.

Individuals with prior colorectal cancer, hereditary colorectal cancer syndrome, inflammatory bowel disease, or prior colectomy were excluded.

Data were analysed from 2022-2024. The main outcomes were detection of colorectal cancer, advanced adenoma, and advanced neoplasia overall by age and by prior adenoma finding (advanced vs non-advanced).

An important limitation of the study was its cross-sectional design, the study authors noted. The follow-up time was limited, and colorectal cancer may take many years to develop. In addition, the study population was from a large healthcare system and limited to patients with prior adenoma. The results might not be generalisable to unscreened patients who could be at higher risk, they said.

Study details

Surveillance colonoscopy findings in older adults with a history of colorectal adenomas

Jeffrey Lee,  Abhik Roy,  Christopher Jensen et al.

Published in JAMA Network on 16 April 2024

Abstract

Importance
Postpolypectomy surveillance is a common colonoscopy indication in older adults; however, guidelines provide little direction on when to stop surveillance in this population.

Objective
To estimate surveillance colonoscopy yields in older adults.

Design, Setting, and Participants
This population-based cross-sectional study included individuals 70 to 85 who received surveillance colonoscopy at a large, community-based US health care system between January 1, 2017, and December 31, 2019; had an adenoma detected 12 or more months previously; and had at least 1 year of health plan enrolment before surveillance.
Individuals were excluded due to prior colorectal cancer (CRC), hereditary CRC syndrome, inflammatory bowel disease, or prior colectomy or if the surveillance colonoscopy had an inadequate bowel preparation or was incomplete. Data were analyzed from September 1, 2022, to February 22, 2024.

Exposures
Age (70-74, 75-79, or 80-85 years) at surveillance colonoscopy and prior adenoma finding (ie, advanced adenoma vs nonadvanced adenoma).

Main Outcomes and Measures
The main outcomes were yields of CRC, advanced adenoma, and advanced neoplasia overall (all ages) by age group and by both age group and prior adenoma finding. Multivariable logistic regression was used to identify factors associated with advanced neoplasia detection at surveillance.

Results
Of 9740 surveillance colonoscopies among 9601 patients, 5895 (60.5%) were in men, and 5738 (58.9%), 3225 (33.1%), and 777 (8.0%) were performed in those aged 70-74, 75-79, and 80-85 years, respectively. Overall, CRC yields were found in 28 procedures (0.3%), advanced adenoma in 1141 (11.7%), and advanced neoplasia in 1169 (12.0%); yields did not differ significantly across age groups. Overall, CRC yields were higher for colonoscopies among patients with a prior advanced adenoma vs non-advanced adenoma (12 of 2305 [0.5%] vs 16 of 7435 [0.2%]; P = .02), and the same was observed for advanced neoplasia (380 of 2305 [16.5%] vs 789 of 7435 [10.6%]; P < .001). Factors associated with advanced neoplasia at surveillance were prior advanced adenoma (adjusted odds ratio [AOR], 1.65; 95% CI, 1.44-1.88), body mass index of 30 or greater vs less than 25 (AOR, 1.21; 95% CI, 1.03-1.44), and having ever smoked tobacco (AOR, 1.14; 95% CI, 1.01-1.30). Asian or Pacific Islander race was inversely associated with advanced neoplasia (AOR, 0.81; 95% CI, 0.67-0.99).

Conclusions and Relevance
In this cross-sectional study of surveillance colonoscopy yield in older adults, CRC detection was rare regardless of prior adenoma finding, whereas the advanced neoplasia yield was 12.0% overall. Yields were higher among those with a prior advanced adenoma than among those with prior non-advanced adenoma and did not increase significantly with age. These findings can help inform whether to continue surveillance colonoscopy in older adults.

 

JAMA Network article – Surveillance colonoscopy findings in older adults with a history of colorectal adenomas (Open access)

 

Medpage Today article – How Old Is Too Old for Surveillance Colonoscopy? (Open access)

 

See more from MedicalBrief archives:

 

Colonoscopy may not be gold standard of colon cancer screening – large randomised trial

 

Updated US guidelines for colorectal cancer screenings

 

Routine bowel cancer testing in over-50s not recommended

 

 

 

 

 

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