Are Older Adults Being Appropriately Screened for Colorectal Cancer?

Investigators find limited use of individualized screening and suboptimal rates of follow-up in a new study in the American Journal of Preventive Medicine

Ann Arbor, MI, June 22, 2016

Who should consider colorectal cancer (CRC) screening and why? CRC is a common and costly disease, largely of the elderly, with nearly 25% of cases diagnosed among patients aged 75-84 years, but the guidelines for CRC screening of Americans aged 75 or older vary according to the source. In a study published in the American Journal of Preventive Medicine, researchers found that CRC screening, consistent with recommendations of the U.S. Preventive Services Task Force, is not widely used by this segment of the population even though some patients are healthy and may benefit, and that appropriate follow-up is not taking place in a timely manner for some older adults.

“Completion of CRC screening—including follow-up of abnormal tests—among the elderly is an understudied area that is important for patients, clinicians, policymakers, and researchers to consider so that screening resources are directed to those who may benefit most,” explained lead investigator Carrie N. Klabunde, PhD, of the Office of Disease Prevention, National Institutes of Health, Rockville MD.

Investigators analyzed the medical records of close to 850,000 patients enrolled in three integrated health systems, part of the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium. They were 65 to 89 years old and were members of Group Health in Washington State and northern Idaho, Kaiser Permanente, Northern California or Kaiser Permanente, Southern California from January 1, 2011, through December 31, 2012.

Two aspects of healthcare were examined in detail:  what proportion of patients were up-to-date with CRC screening, and, for those screened with fecal blood tests, what was the likelihood of receiving a follow-up colonoscopy within three months after a positive result? Further, investigators analyzed whether age or the presence of other medical conditions has greater influence on patients’ likelihood of undergoing CRC screening or follow-up.

Researchers found that age has a greater influence than comorbidity, the presence of other chronic diseases or conditions, on CRC use in the elderly. “This finding is consistent with practice guidelines that emphasize age cut offs in determining who should be screened. The physicians and health systems represented in this study appear to be adhering to age-focused guidelines. However, the lack of tools to assist clinicians and elderly patients in shared decision making about screening that incorporates the patient’s age, health status, preferences, and ability to tolerate screening tests and interventions presents a significant challenge to implementing guidelines that call for more-individualized recommendations,” noted Dr. Klabunde.

The study determined that 72% of all individuals aged 65–89 years were up-to-date with screening. Of those up-to-date by fecal blood testing and having a positive result, 65% received follow-up colonoscopy within three months. However, these estimates varied by patient age and comorbidity. Comorbidity was more strongly related to timely follow-up than to screening up-to-date. In all age groups, considerable numbers of patients with no or low comorbidity were not up-to-date with screening or did not receive timely follow-up.

Because all of the participants were insured members of integrated health systems with extensive patient tracking, it is a concern that timely follow-up after a positive fecal blood test decreases with increasing age and comorbidity. Small primary care practices may lack such tracking, leading to even lower follow-up rates.

The authors conclude, “There are many opportunities for improvement in screening completion among the elderly. Primary care practices need to develop and integrate systems to support individualized as opposed to age-based decision making, including risk assessment tools that consider age and comorbidity in estimates of benefits and harms. More research is needed to understand facilitators of and barriers to completing CRC screening, including timely follow-up of abnormal tests, in the elderly.”

---

Notes for editors
The article is "Influence of Age and Comorbidity on Colorectal Cancer Screening in the Elderly," by Carrie N. Klabunde, PhD, Yingye Zheng, PhD, Virginia P. Quinn, PhD, Elisabeth F. Beaber, PhD, Carolyn M. Rutter, PhD, Ethan A. Halm, MD, MPH, Jessica Chubak, PhD, Chyke A. Doubeni, MD, MPH, Jennifer S. Haas, MD, MSc, Aruna Kamineni, PhD, Marilyn M. Schapira, MD, MPH, Pamela M. Vacek, PhD, Michael P. Garcia, MS, Douglas A. Corley, MD, PhD, on behalf of the PROSPR consortium (doi:10.1016/j.amepre.2016.04.018). It will appear in the American Journal of Preventive Medicine, volume 50, issue 11 (2016), published by Elsevier.

Full text of this article is available to credentialed journalists upon request; contact Angela J. Beck at +1 734 764 8775 or ajpmmedia@elsevier.com. Journalists wishing to interview the authors may contact them via Deborah Langer, Senior Communications Advisor, NIH Office of Disease Prevention, at langerdh@od.nih.gov.

About the American Journal of Preventive Medicine
The American Journal of Preventive Medicine is the official journal of The American College of Preventive Medicine and the Association for Prevention Teaching and Research. It publishes articles in the areas of prevention research, teaching, practice and policy. Original research is published on interventions aimed at the prevention of chronic and acute disease and the promotion of individual and community health. The journal features papers that address the primary and secondary prevention of important clinical, behavioral and public health issues such as injury and violence, infectious disease, women's health, smoking, sedentary behaviors and physical activity, nutrition, diabetes, obesity, and alcohol and drug abuse. Papers also address educational initiatives aimed at improving the ability of health professionals to provide effective clinical prevention and public health services. The journal also publishes official policy statements from the two co-sponsoring organizations, health services research pertinent to prevention and public health, review articles, media reviews, and editorials.

The American Journal of Preventive Medicine, with an Impact Factor of 4.465, is ranked 14th in Public, Environmental, and Occupational Health titles and 16th in General & Internal Medicine titles for total number of citations according to the 2015 Journal Citation Reports® published by Thomson Reuters, 2016.

About Elsevier
Elsevier is a world-leading provider of information solutions that enhance the performance of science, health, and technology professionals, empowering them to make better decisions, deliver better care, and sometimes make groundbreaking discoveries that advance the boundaries of knowledge and human progress. Elsevier provides web-based, digital solutions — among them ScienceDirect, Scopus, Research Intelligence and ClinicalKey— and publishes over 2,500 journals, including The Lancet and Cell, and more than 35,000 book titles, including a number of iconic reference works. Elsevier is part of RELX Group, a world-leading provider of information and analytics for professional and business customers across industries. www.elsevier.com

Media contact
Angela J. Beck, PhD, MPH
Managing Editor, Elsevier
+1 734 764 8775
ajpmmedia@elsevier.com