Many Colonoscopies for Older Adults May be
Inappropriate, Study Says
Unnecessary screenings are almost 40% for those
76 to 85; 23.4% for all 70 and older. Second study finds seniors just
keep on getting cancer screenings without results.
March 11, 2013 – Almost 1 of every 4 colonoscopies
performed in Medicare beneficiaries 70 years and older in 2008-2009 in
Texas and across the country were potentially inappropriate according to
age-based screening recommendations or the results of a previous
A study by Kristin M. Sheffield, Ph.D., and
colleagues of the University of Texas Medical Branch, Galveston, that
analyzed Medicare claims data for Texas and a sample from the United
States, revealed the problem in an Online First article today in the
American Medical Association’s JAMA Internal Medicine.
The study background highlights increasing evidence
of overuse of the procedure and that some Medicare patients with
negative findings at screening colonoscopy may be undergoing another
screening too early.
Colonoscopy repeated within 10 years after negative
screening results represents overuse based on current guidelines.
Screening colonoscopy performed in the oldest age groups may also
represent overuse according to guidelines from the US Preventive
Services Task Force (USPSTF) and the American College of Physicians.
The USPSTF recommends screening for colorectal
cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy
in adults, beginning at age 50 years and continuing until age 75 years.
The risks and benefits of these screening methods
vary. The USPSTF recommends against routine screening for colorectal
cancer in adults 76 to 85 years of age. There may be considerations that
support colorectal cancer screening in an individual patient.
Older People Just Keep on Getting Cancer Screenings
Even When Nothing Appears
In another Online First report by JAMA Internal
Medicine it was found that many older people had never discussed ending
cancer screenings with their doctor or considered stopping on their own.
An interview study by Alexia M. Torke, M.D., M.S.,
of the Indiana University Center for Aging Research, Indianapolis, and
colleagues, sought to examine older adults’ perspectives on cancer
screening cessation and their experiences communicating with physicians
on the topic.
The study included 33 older adults (ranging in age
from 63 to 91 years) presenting to a senior health center.
Undergoing screening tests was perceived by
participants as “morally obligatory.”
For many of the older adults who were interviewed,
stopping screening would be a major decision. Participants also
indicated they were skeptical about the role of statistics and the
recommendations of government panels in screening decisions, the results
“Effective strategies to reduce non-beneficial
screening may include discussion of the balance of risks and benefits,
complications, or burdens,” the study concludes.
This work was funded by grants from the National
Institute on Aging.
The USPSTF recommends against screening for
colorectal cancer in adults older than age 85 years. The USPSTF
concludes that the evidence is insufficient to assess the benefits and
harms of computed tomographic colonography and fecal DNA testing as
screening modalities for colorectal cancer.
The background on the study also reports complications from colonoscopy are
more likely in people aged 75 years or older.
The study results show that 23.4 percent of all
colonoscopies performed with patients age 70 or older in the Texas study were inappropriate.
Breaking the results down by age group shows
inappropriate procedures in -
9.9, in patients aged 70 to 75,
38.8% in those 76 to 85, and
24.9% in patients or 86 years or older.
There was considerable variation across the 797
colonoscopists in the percentages of colonoscopies performed that were
Seventy three colonoscopists had percentages
significantly above the mean (23.9%), ranging from 28.7% to 45.5%, and
119 had percentages significantly below the mean (23.9%), ranging from
6.7% to 18.6%.
The colonoscopists performing these procedures with
percentages significantly above the mean were more likely to be
surgeons, graduates of U.S. medical schools, medical school graduates
before 1990, and higher-volume colonoscopists than those with
percentages significantly below the mean.
Colonoscopist rankings were fairly stable over time
(2006-2007 vs 2008-2009). There was also geographic variation across
Texas and the United States, with percentages ranging from 13.3% to
34.9% in Texas and from 19.5% to 30.5% across the United States.
“Inappropriate use of colonoscopy involves
unnecessary risk for older patients and consumes resources that could be
used more effectively,” the study concludes.
This research was supported by a grant from the
Comparative Effectiveness Research on Cancer in Texas, Cancer Prevention
and Research Institute of Texas; grants from the National Institutes of
Health and the University of Texas Medical Branch Clinical and
Translational Science Award.
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