colonoscopy screening in the elderly???

A recent observational study of Medicare recipients found that those 70-79 years old seemed to benefit from colorectal carcinoma (CRC) screening (see colonoscopy after age 70 AIM2016 in dropbox, or doi:10.7326/M16-0758​​). Study sponsored by the NIH. Details:

--1,355,692 Medicare beneficiaries (from 2004-2012) aged 70-79, who were of average CRC risk, assessing 8-year risk for CRC and 30-day risk for adverse events.

--average risk was defined as: no history of adenoma, IBD, colectomy, and no colonoscopy/sigmoidoscopy/fecal occult blood in the past 5 years; and no prior abdominal CT, diagnosis of anemia, GI bleed, other GI symptoms, weight loss within the past 6 months 

--included were those who were "health-conscious", defined as having received at least 2 of the 3 preventive annual Medicare serviced of annual wellness visit, influenza vaccine, and breast or prostate cancer screening​

Results:

--70-74yo, 8-yr risk of CRC was 2.19% (2.00 to 2.37%) in the screening group vs 2.62% (2.56 to 2.67%), so absolute difference of -0.42% (-0.24% to -0.63%)

--75-79yo, 8-yr risk of CRC was 2.84% (2.54 to 3.13%) in the screening group vs 2.97% (2.92 to 3.03%), so absolute difference of -0.14% (-0.41% to +0.16%) -- ie not statistically significant

--70-74yo, excess 30-d risk of adverse events with colonoscopy was 5.6 events per 1000 people (4.4 to 6.8)

--75-79yo, excess 30-d risk of adverse events with colonoscopy was 10.3 events per 1000 people (8.6 to 11.1)

Commentary:

--the current guidelines, as in many guidelines, varies by who is writing them. The USPSTF currently recommends screening by any of several methods, from 50-75 yo in those at average risk (evidence grade "A", with individualized decisions in those 76-84, though the evidence grade here was "C", meaning that they recommend "offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small"

--there are several concerns about drawing major conclusions from this new NIH-sponsored study:

    --although there are 132,000 new cases of CRC in the US per year and 50,000 CRC-related deaths, it is not clear to me that this proportion applies in the more elderly population. As noted in this study of "health conscious" elderly, there was much more morbidity found in the older 75-79 yo cohort (eg hypertension in 80.5% vs 74.9% in the 70-74 yo, ischemic heart disease in 45.3% vs 36.6%). This increased morbidity is likely to translate to more people "dying with the cancer than dying from the cancer".

                --All of this data is from the Medicare database, which, my guess, does not have the most accurate detailed information, and does not even have the CRC-specific mortality​, a pretty useful endpoint for this study... 

    --I am not so sure of the assumption that people who are more "health conscious", as they define it, are in fact healthier/qualify as "average risk". My guess is that the threshold for colonoscopy screening in the elderly varies lots by who the provider is (some may well push continued screening either in the undocumented belief they are helping the patient, they are uncomfortable effectively saying "you are too old to continue screening", etc), and some patients I see request different screens even with considerable morbidity (either they do not want to deal realistically with death/their prognosis, they are pretty somatic and want to  search for problems, etc). And, I would not be surprised if a higher percentage of less healthy patients get flu shots more aggressively (one of their "health conscious" criteria), either because of provider or patient preferences (and the fact that they come in for health care more often, with more opportunities for vaccines). Only a well-designed prospective trial would work to sort this out. ​

    --this study was limited to colonoscopy screening, which has been documented in the past to work much less well in the elderly, with higher numbers of inadequate preps (leading to more colonoscopies with more intensive preps), and (also perhaps related) higher perforation rates, which can lead to major abdominal surgery in an older and higher risk population. So, perhaps not the screening method of choice…

     --the stage-shift found in screening (ie, fewer cases of more advanced CRC lesions in the screened group) certainly is supportive of screening, but again, colonoscopy is not only very expensive but quite invasive, so it really is important to look at real clinical outcomes before making a screening decision (ie, does this stage-shift to higher stage lesions really translate to more morbidity/mortality?)

--it seems to me to be a tad disingenuous to conclude in the abstract that "screening colonoscopy may have had a modest benefit in preventing CRC in beneficiaries aged 70 to 74 years and a smaller benefit in older beneficiaries", but then in the last paragraph, having basically the same sentence, but with the qualification "and a smaller (if any) benefit in those who are older" (my emphasis). The reality is that many busy clinicians rely on the accuracy of the abstract and may not read the whole article, especially in primary care practice which is not only really busy, but requires clinicians to read and assimilate literature from all of the specialties. The above article also tends to minimize the adverse effects, stating they were "low but greater among older persons". But, the rate was twice as high, and I would not be surprised if the actual effect of these adverse outcomes, in terms of resulting functional impairments, increases in an older population (they just don't bounce back as well even from less-than-severe adverse effects). 

--and, this is really my main criticism of the take-home message of this study: I would phrase the conclusion more like "there is no clear evidence that screening colonoscopy offers any significant benefit in those 75-79 years old, that the possible benefit in terms of decreasing CRC diagnosis may translate even less into real morbidity and mortality benefit in this age group, and  that there was almost a doubling of adverse events in this pretty susceptible population." I personally do think that a healthy 79 yo, who really does have a realistic life expectancy (eg, the healthiest 25% of women aged 80 has a 17 year life expectancy, and men 13 years), might realize actual clinical benefit by diagnosing and treating CRC early, especially since treatment for early lesions is pretty benign, but I have adopted FIT testing as my preferred non-invasive CRC testing, which should help winnow the colonoscopies and their adverse effects to a much smaller exposed group, and one with a higher yield for benefit over risks.