Consider Life Expectancy in Surveillance Colonoscopy Advice

Most older adults with low-risk surveillance colonoscopy findings and/or limited life expectancy are advised to undergo a repeat procedure in the future, according to a new study.

Among nearly 10,000 Medicare beneficiaries, the likelihood of finding advanced polyps or colorectal cancer (CRC) on surveillance colonoscopy was low. Yet, among patients for whom any follow-up recommendation ― either for or against colonoscopy ― was available, the vast majority (87%) were advised to return for the procedure in the future, even if their life expectancy was limited or there were no significant findings on their surveillance colonoscopy.

“These findings suggest that recommending against future surveillance colonoscopy in older adults with low-risk colonoscopy findings and/or limited life expectancy should be considered more frequently than is currently practiced,” say Audrey Calderwood, MD, with Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, and colleagues.

Because of the lack of clear guidance about when to stop recommending colonoscopies to older patients, it is not surprising that physicians recommend surveillance even for patients with low life expectancy, Ziad Gellad, MD, with Duke University Medical Center, Durham, North Carolina, told Medscape Medical News.

“As someone who performs these procedures, I can tell you that it is not easy to tell patients that they are too old to get preventive care, especially patients in whom your only interaction is the procedure itself,” said Gellad, who wasn’t involved in the study.

The study was published online March 13 in JAMA Internal Medicine.

Key Findings

For older adults, surveillance after prior findings of colon polyps is the most frequent indication for colonoscopy. Data suggest that an estimated 5.6 million adults older than 75 will undergo follow-up colonoscopy annually by 2024.

For older adults with polyps, current guidelines recommend individualized decision-making about surveillance colonoscopy. That includes weighing the potential benefits (identifying and removing meaningful lesions to prevent CRC) against the burdens and potential harms (such as bleeding or perforation).

While most colon polyps are not harmful, a subset of polyps, if allowed to grow, can develop into cancer over 10 to 15 years. This long biological timeline highlights the importance of considering life expectancy in deciding for whom surveillance colonoscopy should be recommended, Calderwood and colleagues note.

Using data from the New Hampshire Colonoscopy Registry, which is linked with the Medicare claims database, they evaluated surveillance colonoscopy findings and follow-up advice according to severity of findings and patients’ estimated life expectancy for 9831 adults (mean age, 73; 54% men).

Life expectancy was 10+ years for 57.5% of patients, 5 to <10 years for 35%, and <5 years for 7.5%.

Overall, 791 patients (8%) were found to have advanced polyps (7.8%) or CRC (0.2%) on surveillance colonoscopy.

Recommendations to stop or continue future colonoscopy were available for 5281 patients (53.7%). Among them, 4588 (86.9%) were recommended to return for future colonoscopy, even when there were no significant colonoscopy findings or the patient’s life expectancy was limited.

Compared with life expectancy of <5 years, longer life expectancy was associated with advice to return for future colonoscopy regardless of clinical findings, with adjusted odds ratios of 21.5 and 2.7, respectively, for life expectancy of ≥10 years and of 5 to <10 years.

Among patients with no significant findings, 95% of those with life expectancy of ≥10 years were recommended to undergo repeat colonoscopy down the road, compared with 58% of those with estimated life expectancy of <5 years.

Among patients expected to live 5 to <10 years, future repeat colonoscopy was recommended for 75% who had no significant findings, 82% with one or two small polyps, and 88% with multiple polyps, advanced polyps, or CRC.

The recommended time to repeat colonoscopy was greater than life expectancy for 6.6% of patients with <5 years of life expectancy and 6% with 5 to <10 years of life expectancy.

Nuanced Decisions

The findings “may help refine decision-making” about the potential benefits and harms of pursuing or stopping surveillance colonoscopy for older adults who have a history of polyps, Calderwood and colleagues say.

The risk for a colonoscopy complication has been estimated at 26 per 1000 people, they note. That’s nearly 10 times greater than the potential benefits seen in their study (ie, identification of CRC in 23 of 9831 people, or about 2.3 per 1000).

In the study cohort, 10% of patients had comorbid conditions that have been associated with a higher risk for colonoscopy complications. Those with life expectancy of <5 years had higher rates of inadequate bowel preparation, which also is associated with increased risk for colonoscopy complications, including perforation.

Calderwood and colleagues suggest that clinicians use evidence regarding life expectancy and neoplasia progression to modify their recommendations for surveillance colonoscopy for older adults in the following ways:

1. If life expectancy is <5 years, recommend against surveillance.

2. If life expectancy is 5 to <10 years and the patient has only low-risk polyps, recommend against surveillance.

3. If the patient is healthy with a life expectancy of 10+ years and has recently been found to have advanced polyps, recommend future surveillance colonoscopy, with a caveat that the ultimate decision is dependent on health and priorities at the time the colonoscopy is due to be performed.

4. If future health is unknown or unclear, avoid giving definitive recommendations for future surveillance to allow the flexibility of deciding on the basis of risk and benefit when the time comes.

In comments to Medscape Medical News, Gellad noted that an assessment of patient life expectancy “is not readily accessible at the point of care. These are nuanced decisions that require shared decision-making. Sometimes that is best handled outside the procedure setting.”

Support for the study was provided by the National Cancer Institute. The authors have disclosed on relevant financial relationships. Gellad is a consultant for Merck & Co. and Novo Nordisk and is a co-founder of Higgs Boson Inc.

JAMA Intern Med. Published online March 13, 2023. Abstract

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