AD Muller

BE Sirovich

DA Fisher

JS Mandel

JV Selby

LC Walter

Louise C. Walter

NN Baxter

P Hewitson

Richard M. Hoffman

English

PubMed

Springer - Publisher Connector

EDITORIALS
Colorectal Cancer Screening in the Elderly: The Need for Informed
Decision Making
Richard M. Hoffman, MD, MPH1 and Louise C. Walter, MD2
1New Mexico VA Health Care System, University of New Mexico, Albuquerque, NM, USA; 2San Francisco VA Medical Center, University of
California, San Francisco, CA, USA.
J Gen Intern Med 24(12):1336–7
DOI: 10.1007/s11606-009-1121-7
© Society of General Internal Medicine 2009
C olorectal cancer screening works! We have convincingevidence from randomized trials of fecal occult blood
tests (FOBT) showing that colorectal cancer screening reduces
disease-specific morbidity and mortality1. Case-control studies
suggest that endoscopy is also effective2–4. Nonetheless, only
about 60% of eligible adults are currently screened for
colorectal cancer5. In contrast, nearly 75% of women are
currently screened for breast cancer6, which has a similar
level of evidence for efficacy as colorectal screening. More than
70% of men are currently screened for prostate cancer, which
has uncertain efficacy7. The discordance between evidence and
uptake of colorectal cancer screening has sparked consider-
able efforts to increase screening rates. However, the report by
Kahi and colleagues suggests that these efforts may have the
unintended consequence of promoting screening recommen-
dations that fail to adequately consider the risks and benefits
of screening in the context of a patient′s health status and life
expectancy8.
Perhaps cancer screening is like the forward pass in
football. Darrell Royal the legendary coach at the University
of Texas has said, “When you throw a pass, only three things
can happen, and two of ‘em are bad.” Colorectal cancer
screening can reduce morbidity and mortality, the supreme
accomplishment of a screening program. However, the abso-
lute benefit to a screened population is small; most people will
not benefit because they do not have early-stage colorectal
cancer or polyps destined to become malignant. The Minnesota
Colon Cancer Control Study showed that annual FOBT
screening reduced colorectal cancer mortality by about 3
deaths per 1000 people screened after 13 years of follow up9.
Similarly, screening reduced the risk for cancer diagnosis by
just 7 per 1,000 people screened after 18 years of follow up10.
This small likelihood of future benefit must then be weighed
against the more immediate potential downsides of screening,
including false positive tests, the costs and risks of invasive
diagnostic tests, treatment complications, and the risk for
overdiagnosing cancer—finding disease that is not destined to
cause any problems during a patient′s lifetime.
The latter problem is particularly pertinent for cancer
screening in sick and elderly patients. To minimize inappro-
priate and potentially harmful screening, the US Preventive
Services Task Force has recently provided explicit guidelines—
no screening after age 85 and personalized screening decisions
for those ages 76 to 8511. These recommendations are partly
based on the trial data showing that colorectal cancer
survival curves did not diverge until 5 years after the start
of screening. This interval reflects that it often takes many
years between when a cancer could be first detectable by
screening until when it would have grown large enough to
cause symptoms or death. The recommendation for “person-
alized” screening decisions really is a call for informed
decision making. Older patients, especially those who have
serious medical illnesses, need to be aware that they are
least likely to live long enough to receive any benefit from
cancer screening and more likely to experience the complica-
tions from tests and treatments.
The study by Kahi and colleagues did not address whether
physicians would elicit patient preferences or support in-
formed decision-making, but the fact that respondents
reported that they would offer screening to patients over age
85 or to 75-year-old patients with cancers or severe heart
failure is disconcerting. These patients clearly are very unlikely
to derive any benefit from screening and are at substantial risk
for being harmed. While these are survey data and respon-
dents were presented with hypothetical scenarios, it appears
that actual screening practices may indeed be quite inappro-
priate. A recent cohort study of older veterans at four VA
medical centers used linked VA and Medicare data to describe
screening practices12. During calendar years 2001 and 2002,
37.6% of veterans aged 80 and older who were due for
colorectal cancer screening underwent screening with FOBT,
endoscopy, or barium enema. Strikingly, among this group,
the screening rate was 34% for those with severe comorbidity
(defined by Charlson–Deyo scores ≥ 4), only slightly lower than
the 38% screening rate for those who had comorbidity scores
of 0.
Why is this happening? Several authors have suggested that
organizational zeal to boost screening rates by converting
practice guidelines into performance measures can increase
the rate of inappropriate screening in the sick and elderly13,14.
Similarly, public service messages targeting the public may
oversimplify the screening message—“just do it”—rather than
presenting accurate, balanced information about the pros and
cons of screening. Such oversimplified messages likely con-
tribute to why many patients do not make informed decisions
about cancer screening and why frail elderly patients continue
to undergo cancer screening, even when the risks are sub-
stantial and the benefits are remote.
What can be done about this? Clearly, organizations need to
more carefully balance performance measures and financial
incentives with evidence-based guidelines. Quality-of-care
JGIM
Published online October 2, 2009
1336
assessments must identify and reward efforts that target
patients most likely to benefit from screening rather than
those efforts that merely increase screening rates. Optimizing
the targeting of cancer screening also may require changes in
how preventive care is delivered. The current system for
delivering preventive care relies on finding opportunities for
screening when patients see clinicians for medical problems,
which targets screening to elderly patients with more serious
comorbid conditions because they see clinicians more fre-
quently. This system misses healthy patients who see clini-
cians less frequently. In addition, both patients and clinicians
need to be more aware of the potential risks associated with
screening, especially for persons with advanced age and
serious comorbidities. When two out of three outcomes for
the forward pass are bad, the coach and players need to
carefully study the playbook and make an informed decision.
Corresponding Author: Richard M. Hoffman, MD, MPH; New
Mexico VA Health Care System, University of New Mexico, 1501
San Pedro Drive SE, Albuquerque, NM 87108, USA (e-
mail: rhoffman@unm.edu).
REFERENCES
1. Hewitson P, Glasziou P, Watson E, Towler B, Irwig L. Cochrane
systematic review of colorectal cancer screening using the fecal occult
blood test (hemoccult): an update. Am J Gastroenterol. 2008;103
(6):1541–9.
2. Selby JV, Friedman GD, Quesenberry CP Jr., Weiss NS. A case-control
study of screening sigmoidoscopy and mortality from colorectal cancer. N
Engl J Med. 1992;326(10):653–7.
3. Muller AD, Sonnenberg A. Protection by endoscopy against death from
colorectal cancer. A case-control study among veterans. Arch Intern
Med. 1995;155(16):1741–8.
4. Baxter NN, Goldwasser MA, Paszat LF, Saskin R, Urbach DR, Rabe-
neck L. Association of colonoscopy and death from colorectal cancer.
Ann Intern Med. 2009;150(1):1–8.
5. Use of colorectal cancer tests–United States, 2002, 2004, and 2006.
MMWR Morb Mortal Wkly Rep. 2008;57(10):253–8.
6. Use of mammograms among women aged > or = 40 years–United States,
2000–2005. MMWR Morb Mortal Wkly Rep. 2007;56(3):49–51.
7. Sirovich BE, Schwartz LM, Woloshin S. Screening men for prostate
and colorectal cancer in the United States: does practice reflect the
evidence? Jama. 2003;289(11):1414–20.
8. Kahi CJ, van Ryn M, Juliar B, Stuart JS, Imperiale T. Provider
recommendations for colorectal cancer screening in elderly veterans. J
Gen Intern Med. 2009. doi:10.1007/s11606-009-1110-x
9. Mandel JS, Bond JH, Church TR, et al. Reducing mortality from
colorectal cancer by screening for fecal occult blood. Minnesota Colon
Cancer Control Study. N Engl J Med. 1993;328(19):1365–71.
10. Mandel JS, Church TR, Bond JH, et al. The effect of fecal occult-blood
screening on the incidence of colorectal cancer. N Engl J Med. 2000;343
(22):1603–7.
11. Screening for colorectal cancer: U.S. Preventive Services Task Force
recommendation statement. Ann Intern Med. 2008;149(9):627–37.
12. Walter LC, Lindquist K, Nugent S, et al. Impact of age and comorbidity
on colorectal cancer screening among older veterans. Ann Intern Med.
2009;150(7):465–73.
13. Walter LC, Davidowitz NP, Heineken PA, Covinsky KE. Pitfalls of
converting practice guidelines into quality measures: lessons learned
from a VA performance measure. Jama. 2004;291(20):2466–70.
14. Fisher DA, Galanko J, Dudley TK, Shaheen NJ. Impact of comorbidity
on colorectal cancer screening in the veterans healthcare system. Clin
Gastroenterol Hepatol. 2007;5(8):991–6.
1337Hoffman and Walter: Colorectal Cancer Screening in the ElderlyJGIM


Colorectal Cancer Screening in the Elderly: The Need for Informed Decision Making

Richard M.  Hoffman

Crossref

A case-control study of screening sigmoidoscopy and mortality from colorectal cancer.

Association of colonoscopy and death from colorectal cancer.

Cochrane systematic review of colorectal cancer screening using the fecal occult blood test (hemoccult): an update.

Impact of age and comorbidity on colorectal cancer screening among older veterans.

Impact of comorbidity on colorectal cancer screening in the veterans healthcare system.

Pitfalls of converting practice guidelines into quality measures: lessons learned from a VA performance measure.

Protection by endoscopy against death from colorectal cancer. A case-control study among veterans. Arch Intern Med.

Provider recommendations for colorectal cancer screening in elderly veterans.

Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study.

Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement.

Screening men for prostate and colorectal cancer in the United States: does practice reflect the evidence?

The effect of fecal occult-blood screening on the incidence of colorectal cancer.

Use of colorectal cancer tests–United States,

Use of mammograms among women aged > or = 40 years–United States,

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Colorectal Cancer Screening in the Elderly: The Need for Informed Decision Making

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