Is Surveillance Colonoscopy Needed for Elderly Patients With Adenomas?

While older adults with adenoma at a prior colonoscopy were more likely to be diagnosed with and die from colorectal cancer (CRC) compared with those without adenoma, the cumulative incidence was low and dwarfed by that of death from other causes, a retrospective study suggested.

Among a cohort of U.S. veterans who underwent colonoscopy before age 75, the subsequent 10-year cumulative incidence of CRC was 1.1% in those with adenoma versus 0.7% in those without adenoma (Gray test P<0.001), while the cumulative incidence of CRC mortality was 0.5% and 0.4%, respectively (Gray test P=0.005), reported Samir Gupta, MD, MSCS, of the VA San Diego Healthcare System, and colleagues in JAMA.

However, these rates were far surpassed by the cumulative incidence of non-CRC deaths, which was nearly 50% at 10 years.

Among patients with adenoma, non-CRC mortality at 10-year follow-up was substantially higher than the incidence of CRC, regardless of frailty levels.

“These findings raise major questions about the clinical relevance of surveillance colonoscopy in older adults with prior adenomas after reaching 75 years,” Gupta and team wrote, adding that older adults “may consider deprioritizing surveillance colonoscopy relative to other health concerns.”

In an editorial accompanying the study, Steven H. Itzkowitz, MD, of the Icahn School of Medicine at Mount Sinai in New York City, and colleagues noted that “by providing a much better understanding of the competing risks of death in adults older than 75 years, the study … raises important questions regarding the wisdom of performing surveillance colonoscopy in older adults, even those who are not frail and are at higher risk for CRC due to a history of adenoma.”

They suggested that in addition to benefitting individual patients, conducting fewer routine surveillance colonoscopies will also profit the healthcare system by redirecting resources to “much-needed, first-time screening of individuals” ages 45 and older or other high-risk groups.

This study included U.S. veterans who underwent a colonoscopy prior to age 75 from January 2006 through December 2019 within the VA. Of the 91,952 individuals in the study, 27.8% had an adenoma found on colonoscopy. Median age at the most recent colonoscopy was 71 years, and 98% were men.

Follow-up began at an individual’s 75th birthday and continued until the earliest incident CRC, death, or the end of the study period.

Among individuals with adenoma, the cumulative incidences of CRC, CRC death, and non-CRC death at 5 years were 0.6%, 0.2%, and 22.4%, while the cumulative incidences at 10 years were 1.1%, 0.5%, and 48.2%, respectively.

For those without adenoma, the cumulative incidences of CRC, CRC death, and non-CRC death at 5 years were 0.3%, 0.1%, and 21.0%, while the cumulative incidences at 10 years were 0.7%, 0.4%, and 46.9%, respectively.

At 10 years, the cumulative incidence of CRC was low among individuals with adenoma across all levels of frailty classification (1.7% in the non-frail group and <1% in all other groups). The cumulative incidence of non-CRC death at 10-year follow-up substantially exceeded the incidence of CRC across all levels of frailty (from 34.2% in the non-frail group to 82.0% in the severe frailty group).

Gupta and colleagues acknowledged the study had limitations, including the fact that the study population was almost entirely male.

“Studies are needed with higher representation of females to confirm consistency of results, particularly given that they have lower cumulative lifetime risk for CRC compared with males, yet also experience longer life expectancy under which to experience this risk and potentially benefit from surveillance,” they wrote.